Pine Point Center

Inspectors wroteBased on record review and interview, the facility failed to ensure physician standing orders for constipation, including physician notification, were implemented for 1 of 33 sampled residents. (#16)

Inspectors wroteBased on facility policy, record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for falls (Resident #3) and 3 of 3 residents reviewed for Medication Administration Records (MAR) and Treatment Administration Records (TAR) (Resident #1, #3, and #4).

Inspectors wroteBased on record review and interviews, the facility failed to clarify hospital discharge orders and provide a brand name medication for a resident for 1 of 3 residents reviewed for medications.

Inspectors wroteBased on record reviews and interviews, the facility failed to follow up on laboratory orders when there were no results for a lab ordered for 1 of 3 residents whose record was reviewed for thyroid treatment (Resident #3).

Inspectors wrote3. Resident #11's clinical record contained a Quarterly MDS Assessment, dated 1/11/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. On 4/9/25 at 10:21 a.m., during an interview, the Social Services Director confirmed she does not have a process for scheduling IDT meetings and does not usually provide residents or their representatives advance notification of the meeting(s). 2. Resident #40's clinical record contained Quarterly MDS' dated 12/13/24 and 3/15/25. The record lacked evidence of IDT meetings being held within 7 days of the MDS assessment. In addition, the admission MDS dated [DATE] had a IDT meeting held on 9/16/24 with the resident in attendance, but not the family representative. [...]

Inspectors wrote2. On 4/6/25 at 10:02 a.m., and on 4/7/25 at 12:16 p.m., Resident #27 was observed with an uncovered, open wound on his/her right forearm. Resident #27's clinical record contained a physician order dated 4/3/25 for, Mupirocin External Ointment 2 % (Mupirocin) Apply to Right forearm topically every evening shift for Biopsy for 11 Days. Cover with Band aid, Per dermatology On 4/9/25 at 10:30 a.m., during an interview, the Registered Nurse #2 stated Resident #27's right forearm wound is supposed to be covered with a bandage at all times. At this time, the finding was reviewed with the Unit Manager, and she stated Resident #27 does not typically refuse treatments or remove his/her wound dressing. 3. Resident #4 has diagnoses to include hemiparesis (paralysis) following cerebral infarction (stroke). On 4/6/25 at 11:49 a.m., a surveyor observed a brace on Resident #4's left wrist. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the first quarter (October 1, 2024 - December 31, 2024). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADLs).

Inspectors wroteBased on observations and interviews, the facility failed to properly secure medications on 1 of 2 (Short Stay Unit) units for 2 of 4 days of survey, failed to ensure expired medications were removed from the supply available for use in 2 of 4 treatment/medication carts reviewed and failed to ensure expired lab supplies were removed from supply available for use on 2 of 2 units (Short Stay and Long Term Units).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for floors, walls, the dishwasher and fans/vents, failed to ensure staff were wearing proper hair restraints and failed to ensure that canned goods with a compromised seal were not available for use for 1 of 4 days of survey. (4/6/25)

Inspectors wrote3. On 4/8/25 at 4:04 p.m., a Physical Therapy Assistant (PT-A) was observed exiting the Oak Hill unit, wearing a yellow isolation gown. The PT-A proceeded to walk past the surveyor, located next to the nurse's station and enter the main dining room, where she doffed the isolation gown and then exited the dining room. At this time, the surveyor asked where the PT-A was prior to leaving the Oak Hill unit, and the PT-A stated she had been in a room wearing gloves, a gown, an N95 mask, and eye protection because the resident was on transmission-based precautions (TBP). She then stated, while she was in the room with the resident, the nurse came in and informed her that the TBP had just been lifted and she removed her gloves, mask, and eye protection before she exited the room and should have removed the gown, but she forgot, so she doffed it in the dining room. [...]

Inspectors wroteBased on record review, interviews, and facility policy, the facility failed to thoroughly investigate an Injury of Unknown Origin for 1 of 1 resident reviewed for Injuries of Unknown Origin. (Resident #57)

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured on 1 of 5 units (Pleasant Hill House) for 1 of 4 days of survey (4/6/25).

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's past history of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization and failed to revise the care plan to include those triggers and interventions to prevent re-traumatization for 1 of 2 residents reviewed with a diagnosis of PTSD. (Resident #22)

Inspectors wroteBased on observations, interviews, and a lunch meal test tray, the facility failed to serve food at an appetizing and palpable temperature for 1 of 2 meals observed.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 2 residents reviewed for nutrition (Resident #11).

Inspectors wrote3. Resident #2 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive. 4. Resident #19 was admitted in December 2024. A review of the entire medical record lacked evidence that the facility offered or reviewed with the resident and/or resident representatives or that the resident and/or resident representatives were provided with written information concerning the right to formulate an advanced directive.

Inspectors wroteBased on observations and interview, the facility failed to maintain a clean/sanitary environment on 1 of the 3 units. (Oak Hill House).

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 2 of 2 units and in the Kitchen.

Inspectors wroteBased on interviews, record reviews and observations, the facility failed to provide sufficient staffing to meet the acuity level and resident needs in a timely manner for 3 out of 3 units surveyed. (Pleasant Hill House, [NAME] House and Oak Hill House)

Inspectors wroteBased on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for a nurse aide at least every 12 months, for 2 of 5 sampled Certified Nursing Assistants (CNA) employed greater than 1 year (CNA1, CNA3).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that the clinical records contained accurate documentation for 1 of 6 residents reviewed for medications (# Resident 154), and for 1 of 22 sampled residents ( Resident #111).

Inspectors wroteBased on review of the Quality Assessment and Assurance (QAA) attendance sheets and interview, the facility failed to ensure that they held quarterly Meetings. There is documentation of 3 of 4 meetings and that the required members were in attendance. The Administrator attended 3 of 4 quarterly QAA meetings and the Medical Director attended 3 of 4 quarterly QAA meetings.

Inspectors wroteBased on record reviews and interviews, the facility failed to perform adequate screening and documentation for the pneumococcal vaccination as required for 3 out of 5 Residents screened for vaccinations.

Inspectors wroteBased on observations and interviews, the facility failed to ensure a resident was treated with dignity and respect for 1 out of 14 residents reviewed during survey. (Resident #17) On 3/3/24 at 12:10 p.m., a surveyor observed a loud confrontation among a staff member, a family member, and Resident #17 in the Oak Hill Dining Room. The staff member was seen and heard yelling to the family member I need to talk to you. The staff member was observed pointing their finger at the family member. At this time, the staff member was escorted out of the room by another staff member. On 3/3/24 at 12:45 p.m., during an interview with the family member and Resident #17, they stated the family member had entered the facility and heard 3 staff members talking about Resident #17 in the lobby. The family member overheard one staff member say in an angry manner; I'll take care of this. [...]

Inspectors wroteBased on observation, interviews,record reviews, the facility's bathing schedule and facility's bathing documentation, the facility failed to ensure that resident's preferences were being followed in the area of bathing for 2 of 6 residents reviewed. (Resident #14 and Resident #17)

Inspectors wroteBased on observation and interview, the facility failed to ensure that food was stored in the walk-in fridge correctly and that the kitchen was maintained in a clean and sanitary manner for 2 of 2 kitchen tour observations.

Inspectors wroteBased on observations the facility's quality assurance committee failed to ensure that the plan of correction for identified deficiencies from the Annual Long Term Care Survey Process from 3/4/2024 through 3/6/2024 was effective. The following issue was again identified at this survey.

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative to review and revise the care plan after each assessment for 2 of 31 sampled residents (#14, #18).

Inspectors wroteBased on observation and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 1 of 2 medication rooms and 1 of 3 medication carts observed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident, and/or resident representative, was involved in the development of the resident's baseline care plan and was provided a summary of the care plan for 1 of 8 residents sampled for new admissions (Resident #43).

Inspectors wroteBased on record review and interview, the facility failed to update and include interventions on the resident's current comprehensive care plan for the areas of Activities of Daily Living for 1 of 31 residents sampled (Resident #272).