Pine Trail Nursing and Rehab Center

Inspectors wroteBased on a review of the admission packet, record reviews, and interviews, the facility failed to refund to the resident or resident representative all refunds due to the resident within 30 days from the resident's date of death / discharge from the facility, for 3 of 3 sampled residents, Resident #1, Resident #2, and Resident #3.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate supervision and assistive devices to prevent accidents and injuries, and ensure a safe environment, failed to ensure a complete investigation and follow up were completed for 1 of 2 sampled residents reviewed for falls, Resident #32.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure adequate hot water temperatures for 3 of 31 residents' rooms (Rooms 4, 27 and 28) and 1 of 2 shower rooms reviewed for comfortable temperature levels; failed to ensure 4 of 4 hallways had firmly secured handrails to the walls; failed to ensure the emergency call system cord were long enough and accessible for 5 of 31 resident's bathrooms (Rooms 16, 20, 21, 24, and 27); failed to provide covers for florescent light fixtures located above residents' beds for 60 of 61 beds reviewed for safe, comfortable, homelike environment; and failed to secure residents' personal property and medical records.

Inspectors wroteBased on observations, record review and interview, the facility failed to follow the regular diet menus, affecting 53 of 55 residents receiving a regular diet.

Inspectors wroteBased on observations and interview, the facility failed to ensure food was stored and served in sanitary manner with potential to affect 53 of 55 residents.

Inspectors wroteBased on observation, interviews and record review, the Administrator failed to ensure the facility was administered in a manner that enabled use of its resources effectively and efficiently which affected all 55 residents in the facility at the time of the survey.

Inspectors wroteBased on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F803, Menus Meet Resident Nds/Prep in Adv/Followed; F812, Food Procurement, Store/Prepare/Serve Sanitary; and F925, Maintains Effective Pest Control Program. These repeated deficient practices have the potential to affect all 55 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations and interview, the facility failed to ensure kitchen equipment was maintained in safe operating conditions for 2 of 2 ovens, 1 of 1 freezer and 1 of 1 walk-in refrigerator.

Inspectors wroteBased on observation, interview, and review of exterminator service inspection reports, the facility failed to maintain an effective pest control program, as evidenced by observed insects in all stages of life in 1 of 4 hallways ([NAME]), documentation of inconsistent extermination during the past five months, and voiced resident confirmation during interviews.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure dignity with dining for 2 of 55 sampled residents reviewed for dining, Residents #1 and #14, as eced by standing to feed the resident, assisting one resident later than the roommate and calling the reisdent a feeder.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' accommodation of needs with sufficient staffing to ensure care and services were provided that assured residents maintain the highest practicable physical, mental, and psychosocial well-being as required by the residents' diagnoses or medical condition for 2 of 25 sampled residents, Residents #48 and #52.

Inspectors wroteBased on observation, interview and record review, the facility failed to report an adverse event for 1 of 1 sampled resident reviewed for a fall with fracture, Resident #32.

Inspectors wroteBased on interview and record review, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment within the regulated time frame for 1 of 2 sampled residents reviewed for resident assessments, Resident #46.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided, that included Administration of Intravenous [IV] medication, met professional standard of quality for 4 Licensed Practical Nurses (LPNs) employed by the facility for 1 of 1 sampled resident with a Peripherally Inserted Central Catheter (PICC), Resident #365.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a Peripherally Inserted Central Catheter (PICC) line in a sanitary manner for 1 of 1 sampled resident reviewed for PICC lines, Resident #365.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an assessment before and after respiratory care for 1 of 7 sampled residents observed during medication administration, Resident #365.

Inspectors wrote2. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Depression, and Hypothyroidism. The resident was prescribed Sertraline HCl Tablet 50 MG (milligrams) Give 0.5 tablet by mouth one time a day for Depression Give 25 mg; 0.5 tablet equals 25 mg. Review of the current Medication Administration Record (MAR) for December 2024 revealed there were no behavior monitoring documentations as specified in the order which documents, Monitor for the following behaviors (specify): itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift for monitoring. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 7 sampled residents reviewed during medication administration, Resident #42.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure they had implemented an infection control program that ensured a resident with a Peripherally Inserted Central Catheter (PICC) line was placed on Enhanced Barrier Precautions (EBP) for 1 of 8 sampled residents reviewed for EBP, Resident #365; failed to don proper Personal Protective Equipment (PPE) during perineal care observation for 1 of 1 sampled resident reviewed for indwelling catheter, Resident #19; and failed to ensure meal trays were transported in a sanitary manner for 1 of 3 meal tray carts reviewed during dining observations.

Inspectors wroteBased on observation, record review, and menu review, the facility failed to follow approved menus for 39 of 40 residents who consume foods orally, and failed to follow the fortified food menu for 5 of 5 sampled residents who had orders for fortified foods (Residents #13, #14, #35, #10, and #4).

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner, as evidenced by open and expired food, ceiling and walls in disrepair, rust-laden surfaces, not holding cold foods at required minimum temperature of 41 degrees Fahrenheit, lack of hand hygiene, and observation of pests, potentially affecting 39 of 40 residents who consume food orally.

Inspectors wroteBased on observation, interview, and review of exterminator service inspection reports, the facility failed to maintain an effective pest control program, as evidenced by observed crawling insects in the kitchen and guest bathroom, documented roach activity by the exterminator during the past six months, and voiced resident confirmation during the resident council meeting.

Inspectors wroteBased on observation and interview, the facility failed to provide food in proper form for 12 of 40 residents who consume mechanical soft diets, including sampled residents #4 and #13, and for 5 of 40 residents who consume pureed diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dietary options per resident preferences for Residents #24 and #13, which had the potential to affect 39 of 40 residents who consume food orally.

Inspectors wroteBased on facility policy, observation, record review and interview, the facility failed to ensure a safe environment for a resident diagnosed with Dementia (Resident #6). This failure affected 1 of 4 residents sampled for falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate and complete resident records for 8 of 18 sampled residents whose records were reviewed regarding: 1) Advance Directives (Residents #4, #11, and #42); 2) Accuracy of MDS records (Resident #7 and #11); 3) Physician consults (Resident #5); 4) Immunization Information; 5) Neuro-checks (Resident #6), and 6) Wound Care (Resident #53).

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure documented Interdisciplinary Team (IDT) participation in the care planning process, in conjunction with the comprehensive and quarterly assessments, for 9 of 18 sampled residents whose care plan meetings were reviewed (Residents #5, #35, #42, #52, #7, #49, #27, #30, and #32).