Pine Tree Lodge Nursing Center

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 1 of 2 residents (Resident #1) and 4 of 4 staff ( CNA D, LVN C, LVN B, ADON) reviewed for infection control. The facility failed to ensure CNA D wore gloves carrying a soiled brief in the hallway on 6/24/2026. The facility failed to ensure LVN C washed hands prior to care, placed gloves on while walking to Resident #1's room, and wore proper PPE while transferring Resident #1 on/off toilet on 6/24/2026. The facility failed to ensure ADON wore proper PPE while assisting Resident #1 with transfer on/off toilet on 6/24/2026. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 4 residents reviewed for resident rights. (Resident #1)The facility failed to treat Resident #1 with dignity and respect by CNA B not providing privacy during an incontinent change on 05/28/26. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 3 residents reviewed for ADLs. (Resident #2)The facility failed to ensure Resident #2 received a bath or shower on 05/18/26, 05/22/26, and 05/27/26. This failure could place residents at risk of not receiving care and services to meet their needs, which could result in poor care, feelings of poor self-esteem, and lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 of 13 residents (Resident #49) reviewed for pain management. The facility failed to ensure Resident #49 received her scheduled pain medication (oxycodone) on the following dates and times:1. On 11/03/25, Resident #49 missed her 2 p.m. dose, which resulted in moderate 5 out of 10 pain on the 1-10 pain scale.2. On 11/13/25, Resident #49 missed her 10 p.m. dose, which resulted in severe 9 out of 10 pain on the 1-10 pain scale.3. On 03/23/26, Resident #49 missed her 6 a.m., dose, which resulted in severe 10 out of 10 pain on the 1-10 pain scale before her medication arrived from the pharmacy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of all drugs and biologicals to meet the needs of each resident for 1 of 13 (Resident #49) residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #49 received her scheduled oxycodone (narcotic pain medication) on 10/21/25, 11/03/25, 11/13/25, 11/23/25, and 03/23/26. 2. The facility failed to ensure Resident #49's oxycodone was re-ordered timely to prevent missed doses on 11/03/25, 11/13/25, and 03/23/26. 3. The facility failed to ensure a system was in place for medication reconciliation of narcotic medications and count sheets. 4. [...]

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 2 of 4 residents (Residents #33 and #58) reviewed for infection control practices during medication pass. 1. The facility failed to ensure LVN C performed hand hygiene before or after passing medication to Resident #58, before checking Resident #33's blood sugar and administering insulin, and after leaving Resident #33's room on 03/24/26. 2. The facility failed to ensure LVN C sanitized the blood glucometer machine before and after checking Resident #33's blood sugar. 3. The facility failed to ensure LVN C sanitized the top of the insulin vial before drawing up Resident #33's insulin. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 1 residents reviewed for resident rights. (Resident #1)The facility failed to ensure Resident #1's catheter bag had a privacy cover in place. This failure could cause residents to feel embarrassed and lower their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 18 residents (Resident #40) reviewed for the physical environment. The facility failed to ensure Resident #40's room had adequate lighting. This failure could place residents at risk of falls, a decreased quality of life and an unsafe environment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 18 resident (Residents #30) reviewed for urinary incontinence. The facility failed to ensure staff assisted Resident #30 with using her pure wick system (urine collection system). This failure could place residents at risk for pain, urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1of 1 resident (Resident #40) reviewed for enteral nutrition. The facility failed to ensure Resident #40's physician's order for his enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) was administered during the scheduled amount of time. This failure could affect residents by placing them at risk of dehydration and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 18 residents reviewed for respiratory care. (Resident #22 and Resident #55)The facility failed to ensure Resident #22's and Resident #55's oxygen concentrator had a clean filter. This failure could place residents at risk of respiratory complications or respiratory infection.

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 residents (Resident #54) reviewed for drug storage. The facility failed to securely store over the counter medications, (Nystatin Topical Powder) for Resident #54. This failure could place residents at risk for adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 1 of 18 (Resident #5) residents reviewed for call lights. The facility failed to ensure Resident #5 had a functioning call light. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #21) 1. The facility failed to ensure the dialysis communication forms were fully completed to include the post dialysis assessment for Resident #21. 2. The facility failed to ensure the dialysis order was updated when Resident #21's dialysis days changed on [DATE]. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications and for the accuracy of administering drugs and biologicals to meet the needs of each resident for 1 of 8 residents (Resident #10) reviewed for insulin administration. 1. The facility failed to keep a record of a receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure LVN E primed Resident #10's insulin pen of Fiasp (a rapid-acting insulin) before given. [...]

Inspectors wroteBased on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 3 of 5 residents (Resident's #17, #52, and #56) reviewed for (DRR) Drug Regimen Review. 1. The facility failed to provide documentation of the pharmacy recommendation or rationale for an attempted gradual dose reduction for Resident #17's risperidone (antipsychotic medication), Resident #52's buspirone (antianxiety medication), and Resident #56's paroxetine (antidepressant medication). 2. The facility failed to ensure the Pharmacist Consultant addressed Resident #56's buspirone (antianxiety medication) for a gradual dose reduction. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 residents (Resident #54), 3 of 6 medication carts (Halls 500, 100, and 200), and 1 of 1 treatment cart reviewed for storage of medications. 1. The facility did not ensure medication was not left unattended on Resident #54's bedside table. 2. The facility failed to ensure LVN E kept the 500-hall medication cart secured and was unable to be accessed by unauthorized personnel. on 01/14/25. 3. The facility failed to ensure LVN A kept the Hall 1 and 2 nurse medication carts locked or within her line of sight when not in use on 01/13/25. 4. The facility failed to ensure the Treatment Nurse locked the treatment cart when she left it unattended in the hallway on 01/15/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 meals reviewed. The dietary staff failed to provide food that was palatable for 1 of 3 meals observed on 1/14/25 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to dispose of expired food items. 2) The facility failed to clean the bread [NAME] storage container, microwave, can opener, and utensil drawer. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to coordinate assessments with pre-admission screening and resident review (PASRR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort which included referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 5 residents (Resident #61) reviewed for PASRR Level I screenings. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 6 (Resident #9) residents reviewed for the care plans. The facility failed to ensure a fall mat was beside Resident #9's bed as stated in her care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards by not adequately monitoring the proper storage of oxygen cylinders for 1 of 2 residents (Resident #62). The facility failed to ensure the oxygen cylinder in Resident #62's room was properly secured. This failure could place the resident at risk for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 65 residents (Resident #35) reviewed for respiratory care. The Facility failed to ensure Resident #35 nebulizer mask was bagged when not in use. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 2 of 5 residents (Resident #s 12 and 46) reviewed for infection control. 1. The facility failed to ensure CNA C changed her gloves when she provided incontinent care to Resident #12 on 01/13/25. 2. The facility failed to ensure CNA C did not apply the dirty linen that had fallen to the floor on 01/13/25 to Resident #12. 3. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that each resident was offered a pneumococcal immunization, unless the immunization was medically contraindicated, or the resident had already been immunized for 1 of 5 resident's (Resident #16) reviewed for pneumococcal vaccinations. The facility failed to ensure Resident #16 was offered the pneumococcal vaccination in accordance with the CDC schedule and timing for the pneumococcal vaccine. This failure could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 2 of 4 residents reviewed for range of motion. (Resident #1 and Resident #2) 1. The facility failed to ensure Resident #1 had a contracture prevention device in place for the treatment of his right-hand contracture. 2. The facility failed to ensure Resident #2 had a contracture prevention device in place for the treatment of her right-hand contracture. These failures could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to effectively reseal, label, and date frozen food items. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 5 residents reviewed for resident rights. (Resident #1) The facility failed to ensure staff assisted Resident #1 when answering his call light by turning his call light off and not returning to provide assistance. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 8 resident reviewed for ADLs. (Resident #1, Resident #2, Resident #3) The facility failed to provide Resident #1, Resident #2, and Resident #3 their scheduled bath/showers. This failure 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 poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had a right to reasonable accommodation of resident needs for 1 of 4 residents reviewed for acumination of needs ( Resident #2) Resident #2 pulled his call button to receive assistance with turning and repositioning, getting water to drink and colostomy care. The resident did not receive care for almost 3 hours. This negative practice could endanger the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had the right to privacy for 1 of 3 residents reviewed for privacy. (Resident #1) Resident #1 was not fully dressed when the Maintenance Director entered her room without knocking. This noncompliance was identified as PNC. The noncompliance began on 1/15/24 and ended on 1/15/24. The facility corrected the noncompliance before the survey began. This negative finding could cause the resident embarrassment and discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable wellbeing consistent with the resident comprehensive assessment and care plan for 2 of 3 residents reviewed for quality of life in that: (Resident #1 and Resident #2.) Resident #1 did not receive showers as scheduled and she was not transferred according to her care plan. Resident #2 did not receive care and services as requested when the aide turned off his call light and did not return for 3 hours. His care plan indicated he was to be turned and repositioned every two hours and receive colostomy care as needed. This negative finding could cause resident to have a decline in their physical, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a therapeutic diet as ordered by the physician for 1 of 3 residents reviewed for diets (Resident #1), in that: Resident #1 had a physician order for magic cups three times a day that were not provided for two meals. This negative finding could contribute to Resident weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate MDS was completed for 5 of 19 residents reviewed for MDS assessment accuracy. (Resident #49, #39, #43, #45, and #18). 1. The facility failed to accurately reflect Resident #49's weight loss on the MDS assessment. 2. The facility inaccurately coded Residents #39, #43, #45, and #18 as having received an anticoagulant medication. These failures could place residents at risk for not receiving care and services to meet their needs.

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 in (1 of 1) kitchen reviewed for dietary services. 1) The Dietary staff failed to date all food items. 2) Dietary staff failed to dispose of expired foods items located in the dry storage area. 3) Dietary staff failed to store (2) dented can in a separate area. 4) Dietary staff failed to effectively reseal, label and date frozen food items. 5) The Dietary staff failed test strip on sterilization sink in the three compartment sink 6) The Dietary staff failed to clean the ice machine These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to 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 2 of 5 halls (Hall 4 and Hall 5) and 4 of 13 staff (CNA L, Floor Tech M, CNA C, LVN F) for infection control practices and transmission-based precautions. 1. The facility failed to follow their policy for testing residents following a COVID-19 outbreak in the facility after Resident #500 residing on Hall 5 tested positive for COVID-19 on 12/14/2023. 2. The facility failed to ensure COVID-19 was not spread to residents on Hall 4. 3. The facility failed to ensure that CNA L and Floor Tech M were tested prior to working their shifts following a COVID-19 outbreak in the facility. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 3 of 21 employees (Dietician, ST, and OT) reviewed for required annual trainings. The facility failed to ensure the Dietician received annual HIV training. The facility failed to ensure the Dietician, ST, and OT received annual Restraint training. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV.

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 19 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's comprehensive care plan addressed that she received oxygen. This failure could place residents at risk of not receiving necessary medications and services.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 of 67 residents (Resident #49) reviewed for comprehensive care plans. The facility failed to ensure Resident #49's care plan was updated to indicate weight loss. These failures could place residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for enteral nutrition (Resident #48). The facility failed to ensure LVN F rinsed Resident #48's gastrostomy tube (feeding tube inserted in stomach used for feeding and medication administration) syringe after she administered a medication. This failure could affect residents receiving enteral nutrition and hydration by placing them at risk for gastric infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 4 resident reviewed for quality of care. (Resident #1) The facility failed to obtain the amount of oxygen to be administered to Resident #1. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 6 residents reviewed for pharmacy services. (Resident #54) The facility failed to ensure MA G administered Resident #54's nifedipine (blood pressure medication) extended release correctly. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on interview, and record review the facility failed to immediately consult with the resident physician when there was significant change in the resident physical condition for 1 of 4 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced 35 elevated blood pressure readings in the month of [DATE] . The facility failed to notify the physician when Resident #1 had an unwitnessed fall on [DATE] at approximately 080:00, her BP reading was 177/126. Resident #1 had a change in condition and was sent out to the hospital at approximately 10:45 a.m., her BP reading at that time was 197/102, she died at the hospital the following day. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:00 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1's physician ordered Clonidine for high blood pressure 35 times during the month of [DATE] that resulted in the death of Resident #1. An Immediate Jeopardu (IJ) situation was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. This failure could place residents not receiving blood pressure medications as prescribed at risk for strokes, heart attacks, kidney damage, and even death.