Pine Lodge

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident # 3 was free from neglect. Nurse Aide #137 was assigned to be on one to one supervision with Resident #3 due to multiple falls. NA #137 neglected the resident by leaving the residents room braking the one to one supervision to go to the nurses station to plug up his phone. While he was out of the room Resident #3 got out of bed and fell and sustained a fracture to her facial bones. The neglect perpetrated by Resident #137 resulted in actual harm for Resident #3 when she sustained a [NAME] Fort 1 fracture (A horizontal fracture separating the teeth and hard palate from the upper maxilla. The upper teeth are mobile, but the nose and eyes remain stable). This was true for one (1) of nine (9) residents reviewed for abuse during the long term care survey. [...]

Inspectors wroteBased on observation, record review staff interview and resident interview, the facility failed to provide a safe, comfortable home-like environment by failing to ensure clean bed and bath linens in good condition available for the residents. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #31, #78 and #38. Facility Census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to correctly interpret the results of an investigation related to neglect for Resident #54, #83, #93, and #105. This was true for four (4) of eight (8) residents under the care area of neglect. Resident Identifiers: #54, #83, #93, and #105. Facility Census: 117. a) Facility-Reported Incident On 05/20/2026 at 1:38 PM, a facility-reported incident (FRI) dated 12/11/25 was reviewed. The FRI noted the following, On 12/11/25, Resident #54 alleged to staff that she was not changed all night the night of 12/10/25 into the morning of 12/11/25. The alleged perpetrator Nurse Aide (NA) #139 was suspended pending investigation. Through witness statements and documentation, the assigned CNA (certified nursing assistant) stated that she had changed and checked on Resident #54 multiple times throughout the night. [...]

Inspectors wroteBased upon record review and staff interview, the facility failed to maintain accurate medical records for three (3) residents in the area of Minimum Data Set (MDS), and care plan. Resident identifiers: #2, and #12. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure resident care plans were revised for four (4) residents. The issues included a resident declining assistance with meals, a resident receiving dialysis, a resident preferring to sleep in the dining room and a resident whose discharge status had changed. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #22, #63, and #102. Facility Census: 117.

Inspectors wroteBased on record review, staff interview, resident interview and observation, the facility failed to ensure menus were followed as posted and stated on the resident's tray cards. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #31, #67, #68, #17 and #27. Facility Census: 117.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure food was stored, prepared, distributed, and served in a manner that prevented foodborne illness to the residents. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 117.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure garbage and refuse were disposed of properly in the kitchen. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate and complete record for Resident #62's Physician Order for Scope of Treatment (POST) form, a transfer form for Resident #13, accurate weights for Resident #15. This was true for three (3) of 33 residents reviewed during the survey process. Resident Identifiers: #62, #13, #15. Facility Census: 117. Findings Include: a) Resident #62 On 05/17/26 at 11:45 AM, the POST form was reviewed for Resident #62. The review found the signature of the resident representative was not dated. On 05/18/2026 at 12:02 PM , the Assistant Director of Nursing (ADON) #51 confirmed the resident representative's signature was not dated. b) Resident #13 On 05/19/26 at 6:00 AM, a record review was completed for Resident #13. The review found the resident had been sent to an acute care facility on 02/25/26. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to maintain an infection control program during medication administration for Resident #53 and #62, cleanliness for the East and [NAME] shower rooms, and the facility laundry room. These were random opportunities for discovery. Resident Identifiers: #53, #62. Facility Census: 117. Findings Include: a) Medication Administration On 05/19/26 at 8:00 AM, medication administration was being observed for Resident #53 completed by Licensed Practical Nurse (LPN) #13. When LPN #13 started to obtain the medication for Resident #53, hand hygiene was not completed prior to pulling the medication. Prior to completing an accucheck for the blood sugar level, no hand hygiene was completed. After the accucheck was completed hand hygiene was not completed. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to provide dependent residents with necessary activities of daily living (ADL) for Resident #62's nail care. This was true for one (1) of three (3) residents reviewed under the care area of ADLs. Resident Identifiers: #62. Facility Census: 117. Findings Include: a) Resident #62 On 05/17/2026 at 12:30 PM, an initial interview was held with Resident #62. The resident stated, Look at my nails, they need cut. At this time, the resident's nails were observed to be long and in need of filing. On 05/18/26 at 9:15 AM, the resident was observed in her room. At this time, the nails remained long. On 05/19/26 at 4:45 PM, the Director of Nursing (DON) stated, I think they trimmed them yesterday but let me check. Activities usually does the nail care .they are going to start doing manicures once or twice a month. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure an accident-free environment, of which it has control, for storage of medication for Resident #10. This was a random opportunity for discovery. Resident Identifier: #10. Facility Census: 117. Findings Include: a) Resident #10On 05/17/26 at 12:10 PM, an initial interview was held with Resident #10. An observation of two (2) inhalers and a medication cup containing one (1) TUM at the bedside. At this time, the resident was asked, Do you keep medication at the bedside? The resident responded, I haven't taken them yet .I was getting dressed and putting lotion on. On 05/17/26 at 12:13 PM, Licensed Practical Nurse (LPN) #75 was asked to come into the resident's room. LPN #75 was asked, Is this resident supposed to have medication at bedside? LPN #75 stated, My bad. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure oxygen therapy was maintained for Resident #124 and #15. These were random opportunities for discovery. Resident Identifers: #124 and #15. Facility Census: 117,Findings Include: a) Resident #124 On 05/17/2026 at 12:10 PM, an initial interview was conducted with Resident #124. An observation of the oxygen concentrator found the humidy bottle was empty. An interview was held with Licensed Practical Nurse (LPN) #75 regarding the oxygen therapy and the humidity bottle on 05/17/26 at 12:13 PM. LPN #75 stated, let me go get a new bottle .it should be on there. On 05/17/26 at approximately 2:00 PM, the Administrator was notified. The Administrator confirmed the humidy bottle should not be empty if used with oxygen therapy. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure a medication used in dialysis patients to help decrease the phosphate levels in a residents blood which was ordered to be given outside of the recommened dose or freqency was given only after consultation with the dialysis provider. This was true for one (1) of one (1) residents reviewed for the care area of dialysis during the long term care survey. Resident Identifier: #102. Facility Census: 117.

Inspectors wroteBased on record review, observation and resident interview, the facility failed to ensure a diet was provided that took into the consideration the resident's preferences. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #22. Facility Census: 117. Finings included: a) Resident #22 - On 05/19/26 at 7:25 AM, Resident #22 was observed in the dining room and was not eating her breakfast. The resident stated she received cornflakes and did not like them and would not eat them, The resident reported she disliked hard boiled eggs. The resident's Tray Card stated, 2 bowls of fruit loops (with 'out' handwritten), NO EGGS or pork. and Assorted fruit juices - 8oz. The resident was served cornflakes, two (2) boiled eggs and no juice. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents received therapeutic diets as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #31 and #68. Facility Census: 117.

Inspectors wroteBased on observation, record review, resident interview and staff interview the facility failed to provide a safe, clean, comfortable home like environment by not taking reasonable care to protect residents personal property from loss, and by not ensuring comfortable temperatures in the dining area. This failed practice was found true for (1) one of (3) three residents reviewed for personal property and was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #108. Facility census 113. Findings Include: a) Resident #108 During the initial interview on 06/16/25 at 12:19 PM, Resident #108 stated, I came here in march and some of my stuff is still missing. They say the washing machine is broken and that it will be down for 6 months. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's right to formulate an advanced directive. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #111 and #65. Facility Census: 3.

Inspectors wroteBased on resident interview, staff interview and record review the facility failed to provide treatment in accordance with professional standards of practice by not passing medications at their scheduled administration times. This failed practice was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifier #70. Facility Census 113.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure catheter had proper drainage during a transfer. This was a random opportunity for discovery during the Long-Term Care survey and had the potential to affect a minimal number of residents. Resident Identifier: #104 Facility Census: 113 Findings Include: During an observation on 06/19/25 at 10:55 AM the surveyor observed therapy staff transferring Resident #104 from their wheelchair to stretcher. While transferring the catheter bag was hooked to the transfer belt staff was using to transfer Resident #104. The transfer belt was placed above the waste and not allowing proper drainage that can allow for the possibility for a UTI. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to ensure refrigerator temperatures in a resident's room were maintained and logged in accordance with professional standards for food service safety. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: 36. Facility Census: 113.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a correct and complete medical record was maintained for residents. This was true for two (2) of thirty (30) residents reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: # 65 and # 111. Facility census: 113.

Inspectors wroteBased on record review, resident interviews, staff interviews and observations, the facility failed to ensure all staff were competent and there were Sufficient nursing staff relate: to extremely late and omitted medications, Nursing staff failed to notify the physician and/or not done timely when blood glucose levels are not in the set parameter, showers not provided for dependent residents, missed treatment, lacking in meaningful activities, catheter care, care for tube feedings, staff adhering to infection control practices (including residents that are positive for COVID-19), and staff failed to document and dispense night time ordered snacks. Facility census 117.

Inspectors wroteBased on observation, facility document review, and staff interview the facility failed to post a staff posting that included the census, total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was true for the last quarter and currently. These failed practices had the potential to affect all residents. Facility census 117.

Inspectors wroteBased on record review and staff interview, the facility failed to review and update the Facility Assessment Tool as required. This has the potential to affect all Residents at the facility. Facility Census: 115. Findings Included: a) Facility On 11/12/23 the Facility Assessment Tool was provided by the Director of Nursing. Upon review, it was noted that the information on the Assessment Tool was incorrect and had not been updated since 06/21/22. According to the regulation, the facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and sanitary environment to help prevent the development and transmission of diseases, including Covid-19, during an active Covid-19 outbreak. Linens were not handled appropriately within the laundry room or during transport. Medication administration for Covid-19 positive Resident was not done correctly to prevent the possible spread of Covid-19. Personal Protective Equipment (PPE) was not appropriately worn and discarded after Resident care. Continual Infection Surveillance was not completed for evaluation of proper hand hygiene performance. These failed practices had the potential to affect all residents. Resident identifiers: #28, #167. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement an antibiotic stewardship program that promoted the appropriate use of antibiotics including a system of tracking and monitoring outcomes. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to designate one or more individual(s) as the infection preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115.

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to consider the views of resident council and act promptly upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. This failed practice had the potential to affect more than a limited number of residents. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the physician of an elevated blood glucose level. This was true for three (3) of five (5) residents reviewed for unnecessary medication. Resident identifiers: #56, #42, and #73. Facility census 117.

Inspectors wrotem) Resident #57 On 11/12/23 at 12:49 AM, observation was made of Resident #57's mattress and it was heavily soiled. The bed was occupied by Resident #57. The mattress was bare with no sheets or blankets. Resident stated, I don't want sheets or blankets, I like it this way because of my skin breaking out. The mattress had what appeared to be white/cream colored dried flakes of skin outlining his body. A dried liquid substance was running down the left and right side of the mattress, and the surface of the mattress at the Resident's midsection was covered with a dried white substance and food particle. The soiled mattress was verified by Licensed Practical Nurse (LPN) #27. LPN #27 stated, I'll let someone know it needs cleaned. During observation of care on 11/13/23 9:52 AM, Resident #57's mattress was found to be soiled and dirty. [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview the facility failed to provide care to residents that was required to maintain hygiene to a resident who was dependent for Activities Of Daily Living (ADL) care. This is true for four (4) of eight (8) reviewed for ADL care area during the Long Term Care Survey Process (LTCSP). Resident Identifiers: #24, #61, #1, and #66. Facility Census: 115. Findings Included: a) Resident #24 During an interview on 11/12/23 at 11:44 AM, Resident # 24 stated I don't get showers or bed baths. Observation revealed Resident #24's hair was disheveled and sticking up everywhere. During an interview on 11/13/23 at 10:35 AM, Resident # 24 stated, The night shift (Nurse Aide (NA) #76's name) left me shitty since two (2) AM, and I am still not changed, and I still have not gotten a shower or bed bath. [...]

Inspectors wroteBased on observation, record review, staff interview and resident interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found true for six (6) of six (6) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident Identifier: Resident #85, Resident #62, Resident #96, Resident #22, Resident #82, and Resident #73 . Facility Census: 115. Findings Included: a) Resident #85 During an interview on 11/12/23 at 11:56 AM, Resident # 85 stated there are no activities, I do stuff in my room to keep busy, but they don't do anything. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow Physicians orders in the areas of neurological checks, medication administration, and skin/wound treatments. Resident identifiers: #42, #67, #1, #56, #73, #86, #18 and #28. Facility Census: 115 Findings Included: a) Resident #42 1) Record review on 11/14/23 at 01:04 PM shows resident #42 had an unwitnessed fall on 08/08/23 at 12:45 PM. Status post of the fall he complained of right leg and back pain. He was sent to the local emergency room for X-rays, which were negative, and he returned to the facility on [DATE] at 06:50 PM. Facility policy NSG204 Neurological Evaluation, revision date of 06/01/21 states: Neurological evaluations will be performed as indicated or ordered. When a patient sustains an injury to the head or face and/or has an unwitnessed fall, neurological evaluation will be performed: [...]

Inspectors wroteBased on observation, medical record review, staff interview and resident interview the facility failed to ensure the environment is free from accident hazards over which it has control. Resident #111's cigarettes were in the room and Resident #28's inhaler was left in the room. This failed practice had a potential to affect more than an isolated number of residents. Resident identifier: Resident #111 and Resident #28. Facility Census: 115. Findings Included: a) Resident #111 During the initial tour 11/12/23 at 11:42 AM, Resident #111 had three (3) cigarettes laying on the over bed tables. There was no lighter found. During another observation on 11/13/23 at 10:55 AM , Resident #111 one (1) cigarette was laying on the over the bed table. During an observation on 11/13/23 at 2:00, Resident #111 had no cigarettes on the over the bed table. [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: Resident #85, Resident #266 and Resident #22. Facility Census: 115. a) Test tray On 11/12/23 at 1:08 PM, the temperatures were obtained on the lunch meal tray at the time of service. The following temperatures were obtained by the Dietary Account Manager #108 using her thermometer: -chicken cacciatore: 124 degrees Fahrenheit -mixed vegetables: 110 degrees Fahrenheit -peach slices: 54.5 degrees Fahrenheit -chicken noodle soup: 125 degrees Fahrenheit. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to respect the Residents right to be treated with respect and dignity. This was a random opportunity for discovery. Resident Identifier: #48. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to complete a Pre admission Screening and Resident Review (PASARR) for new diagnosis of Bipolar disorder. This was true for 1 of 2 residents reviewed for PASARR. Resident identifier: #22. Facility Census 115. Findings Include a) Resident #22 A record review on 11/13/23 at 10:00 AM, revealed that Resident #22 received a new diagnosis of Bipolar Disorder on 05/09/22. The Resident was admitted to the facility on [DATE]. A record review on 11/13/23 at 10:00 AM found Resident #22's initial PASARR upon admission did not indicate a diagnosis of Bipolar Disorder. A record review on 11/13/23 at 10:00 AM, of Resident #22 admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/13 did not indicate an active diagnosis of Bipolar Disorder. [...]

Inspectors wroteBased on record review, staff interview, resident interview, and observation the facility failed to properly secure Resident #23's indwelling urinary catheter device. This was true for one (1) of one (1) Residents reviewed for catheter care and had the potential to affect only a limited number of Residents. Resident identifier: #23. Facility census:115.

Inspectors wroteBased on record review and staff interview the facility failed to maintain acceptable parameters of nutritional status by not completing weights/re-weights appropriately. This was true for one (1) of three (3) Residents reviewed for nutrition. Resident identifier: #58 Facility Census: #115 Findings Included: a) Resident #58 On 11/13/23 at 02:20 PM record review shows the following documented weights: 11/13/2023 14:44 150.2 Lbs Wheelchair 11/07/2023 14:12 153.0 Lbs Standing 10/03/2023 13:48 196.5 Lbs Standing 9/25/2023 12:35 199.6 Lbs Standing 9/21/2023 22:33 157.0 Lbs Mechanical Lift 9/26/2023 15:29 Correction The above documentation shows a 43.5 pound weight loss from 10/03/23 until 11/07/23. admission records from the hospital states Resident #58 weighed 162 pounds on 09/12/23. Re-weight on 11/13/23, during the survey, shows the Resident weighs 150.2 pounds. [...]

Inspectors wroteBased on record review, observation and staff interview the facility failed to provide care in accordance with professional standards of practice to prevent complications of enteral feeding for Resident #96 and Resident #97. This was true for two (2) of two (2) residents reviewed for the care area of feeding tube during the long term care survey. Resident Identifier: #96 and #97. Facility Census: 115 Findings Included: a) Resident #96 A review of Resident #96's medical record found the following two (2) orders related to Resident #96 enteral feeding tube: -- Enteral Feed Order: Every 4 (four) hours water flush 240 ML (Milliliters), PEG (Percutaneous Endoscopic Gastrostomy) every 4 (four) hours after each bolus. -- Enteral Feed: Flush Tube with 30 ml of water before and after each medication pass. Flush Tube with a least 15 ml of water between each medication. An observation beginning 12: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all Pharmacy recommendations were answered with a rationale and in a timely manner. This was true for two (2) out of five (5) Residents reviewed for unnecessary medication. Resident identifiers: #56, and #25. Facility census 117.

Inspectors wroteBased on record review and staff interview the facility failed to obtain a consent for Physician ordered psychotropic drugs. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #42 Facility Census: 115 a) Resident #42 On 11/14/23 at 01:32 PM record review shows that Resident #42 has an order for Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 2 tablet by mouth one time a day for Depression and Buspirone HCl Oral Tablet 5 MG (Buspirone HCl) Give 1 tablet by mouth at bedtime for Generalized Anxiety Disorder (GAD.) Resident #42 has an active diagnosis for generalized anxiety disorder and major depressive disorder. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; [...]

Inspectors wroteBased on observation, staff interview, and resident interview, the facility failed to ensure safe and sanitary storage, handling, and consumption of food by not having up to date temperature logs for resident personal refrigerators. This was a random opportunity for discovery. This failed practice was true for 3 of 3 residents. Resident Identifiers #22, # 69, # 42. Facility census: 115. Findings Included: a) Resident #22 An observation on 11/12/23 at 11:45 AM, revealed that resident #22 had a personal refrigerator in her room with a Temperature log sheet filled out until 09/18/23. An interview on 11/12/23 at 11:45 AM, with Resident #22, who has a BIMS of 14 stated, They used to do those and then just stopped. During a record review on 11/13/23 at 2:00 PM, of Policy 031 Titled Food: [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to accurately record the amount of a prescribed snack that was consumed. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: #66, #65, and #39. Facility census 117.

Inspectors wroteBased on observation, resident interview and staff interviews the facility failed to maintain equipment in safe operating conditions. Two (2) Heating, Ventilation and Air Conditioning (HVAC) units were not in safe operating conditions for room [ROOM NUMBER] and room [ROOM NUMBER]. This had the potential to affect a limited number of residents residing in those rooms. Facility Census: 115. Findings Included: a) room [ROOM NUMBER] During the initial tour on 11/12/23 at 11:56 AM, room [ROOM NUMBER]'s HVAC unit was void of a plastic guard. During an interview on 11/12/23 at 11:57 AM, Resident #85 stated, That heater has been missing the vents forever. During another observation on 11/13/23 at 10:56 AM, room [ROOM NUMBER]'s HVAC unit's plastic guard was not there. During an interview on 11/14/23 at 4:31 PM, the Maintenance Director acknowledged the HVAC plastic guard was missing. [...]