Pine Meadows Post Acute

Inspectors wroteBased on observation, interview, record review, review of a U.S. Food and Drug Administration document, and review of the facility's policies, the facility failed to provide a safe, sanitary environment for food production and storage, which could affect 117 of the 117 current residents that received food from the kitchen. During the initial kitchen tour on 09/02/2025, observations revealed staple food bins unlabeled and undated, other commercial mixes out of the original packaging with no opened date, and personal items, including backpack and jacket, stored in the dry storage room on top of canned and packaged foods. Also, temperatures were missing on the logs for the tray line and for the walk-in refrigerator and freezer. Observation of the kitchen ceiling on 09/03/2025 and 09/04/2025 revealed dripping condensation and peeling gray paint on the ceiling. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, sanitary, and comfortable environment, and to prevent the onset and transmission of communicable diseases and infections by failing to disinfect 1 of 9 Hoyer lifts observed.

Inspectors wroteBased on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure one (1) of three (3) residents reviewed for Pre-admission Screening and Resident Review (PASARR), (Resident #94) who had a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health or intellectual disability authority for review.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop an individualized, person-centered activities care plan for one (1) of twenty-three (23) sampled residents (Resident #56).

Inspectors wroteBased on interviews, record review, and facility policy review, it ws determined the facility failed to provide an ongoing program of activities designed to meet the resident's interests for one (1) of twenty-three (23) sampled residents, (Resident #56).

Inspectors wroteBased on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure prompt treatment of a pressure ulcer for one (1) of five (5) residents reviewed for pressure ulcers (Resident #264).

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to serve and store food under sanitary conditions. Observations, on 08/08/2022 and 08/09/2022, revealed dry storage with dented cans; no label on a can; ingredient bins with food thickener, lids not closed; vents in dry storage with dust accumulation; vents in kitchen ceiling with dust and dripping water in front of the walk-in refrigerator and walk-in freezer. Further observations, on 08/11/2022, of the nourishment refrigerator on Unit 1, revealed it was not clean on the lower shelf; no identification on a frozen resident meal, and the boxed cookies were not dated.

Inspectors wrote13.a. Observation, on 08/09/2022 at 3:58 PM, revealed LPN #1, after performing a blood glucose check on Resident #34, returned to the medication cart and opened the top right drawer. He picked up an alcohol pad and wiped only the end of the glucometer and placed the glucometer back in the drawer. Interview with LPN #1, on 08/09/2022 at 3:59 PM, revealed he cleaned the glucometer after each use with an alcohol pad. b. Observation, on 08/11/2022 at 9:00 AM, revealed LPN #3 sanitized her hands and put on gloves before she cleaned the used glucometer with only one (1) Sani-Cloth. LPN #3 failed to take another disinfecting wipe and wipe the meter thoroughly per the manufacturer's instructions. Interview with LPN #3, on 08/11/2022 at 9:02 AM, revealed she cleaned the glucometer after each use with a Sani-Cloth and then let the glucometer sit for two (2) minutes to dry before using again. c. [...]

Inspectors wroteBased on observation, interview, record review, review of the Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH Memo, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidelines, review of the Kentucky Department for Public Health's (KDPH) Long-Term Care Facility COVID-19 bi-weekly County Indicator Map, review of the BinaxNOW Covid-19 Ag Card Instructions, and review of the facility's policies, it was determined the facility failed to conduct COVID-19 testing, twice weekly, for unvaccinated staff based on the community's COVID-19 transmission levels and the facility's COVID-19 outbreak status. The facility failed to conduct testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests; [...]

Inspectors wroteBased on interview and review of the facility's policy, it was determined the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays.

Inspectors wroteBased on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment. Residents complained during resident council of staff smoking outside on facility grounds. Observation revealed evidence of smoking off the Unit 2 exit, in the back parking lot, and at the back stairs.

Inspectors wroteBased on observation, interview, record review, review of the Director of Nursing and the Administrator's Job Descriptions, and review of the facility's policy, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and, failed to ensure infection prevention and control policies and protocols were adhered to for the safety and well being of residents, staff, and visitors. The Administration failed to ensure staff followed the Centers for Disease Control and Prevention (CDC) guidelines and the facility's policies for infection control and prevention (IPC); and COVID-19 testing was conducted per established local, state, and federal regulations. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Multiple breaches of infection prevention and control practices, as stipulated by the Centers for Disease Control and the facility's policies, was observed from 08/08/2022 to 08/11/2022. [...]

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to have documented evidence of COVID-19 vaccination exemptions for those employees who declined to be vaccinated or whose vaccination status was unknown, for State Registered Nurse Aides (SRNA) #19, #20, #21, and Licensed Practical Nurse (LPN) #10.

Inspectors wroteBased on interview, record review, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan in the care area of nutrition, for one (1) of thirty-two (32) sampled residents (Resident #26).

Inspectors wroteBased on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of the United States Pharmacopoeia Standards, review of a medication package insert, https://www.humalog.com/u100, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in two (2) of two (2) medication storage rooms and one (1) of three (3) medication carts. Observation of two (2) medication storage refrigerators located on Unit 1 and Unit 2, on [DATE], revealed the medication refrigerators' temperatures were not maintained between 36- and 46-degrees Fahrenheit (F). [...]