Pine Valley Center for Rehabilitation and Nursing

Inspectors wroteBased on observation and interview the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, twenty-five (25) food items were not properly identified and dated in the kitchen refrigerators, freezers, and food storage areas.

Inspectors wroteBased on observation, record review, and interview the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent and/or treat pressure ulcers for three (3) of eight (8) residents (Residents #59, #91 and #100) reviewed for Pressure Ulcers. Specifically, 1) heel offloading was not implemented as per physician order for Resident #59 who was assessed at risk for pressure ulcers 2) heel offloading was not implemented as per comprehensive care plan and physician order for Resident #91 who was assessed at risk for pressure ulcers and 3) heel offloading was not implemented as per physician order for Resident #100 who was assessed at risk for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for four (4) of six (6) residents (Residents #50, #34, #59, and #91) reviewed for Positioning and Mobility. Specifically, 1) the use of carrot splints was not implemented as per physician order and care plan for Resident #50 with contractures (fingers bent into the palms) of both hands, 2) the use of a left- hand roll brace was not implemented as per physician order for Resident #34, and 3) the use of a right resting hand splint was not implemented as per physician order for Resident #59. Additionally, the use of a left-hand carrot was not implemented as per physician order for Resident #91.

Inspectors wroteBased on interviews and record review the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every three (3) months for one (1) of two (2) residents (Resident #44) reviewed for Resident Assessment. Specifically, a quarterly Minimum Data Set assessment was not completed three (3) months after the completion of the 06/28/2025 annual Minimum Data Set for Resident #44.

Inspectors wroteBased on record review and interview conducted during the recertification survey from 12/15/2025 to 12/22/2024, the facility did not ensure that Minimum Data Set 3.0 Assessments accurately reflected the residents' status for one (1) of seven (7) residents reviewed for Accidents. Specifically, the Minimum Data Set 3.0 annual comprehensive assessment did not identify Resident #9 as an active smoker.

Inspectors wroteBased on observation, Interview, and record review the facility did not ensure they developed and/or implemented 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 needs for one (1) of five (5) residents (Resident #13) reviewed for Environment. Specifically, a care plan was not developed and/or implemented to address Resident #13's known hoarding behavior.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the resident plan of care was reviewed and revised for one (1) of three (3) residents (Resident #13) reviewed for Rehabilitation Services. Specifically, Resident #13 had a care plan intervention for bilateral siderail enablers and was observed without enablers in place. Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #13 was cognitively intact and was independent in rolling to the left and right in bed. The Comprehensive Care Plan related to activities of daily living performance and physical mobility dated 08/28/2025 and last reviewed 09/10/2025 documented Resident #13 used top bilateral bed rails for rolling to the left and right in bed, bed mobility, and transfers from bed. [...]

Inspectors wroteBased on observation and interview the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage. Specifically, the Three East High Side medication cart was found unattended in the unit corridor near the nursing station unlocked with one (1) drawer left open.

Inspectors wroteBased on interview and record review conducted during the abbreviated survey (2626453), the facility did not ensure all alleged violations of abuse were reported immediately, but not later than two (2) hours to the New York State Department of Health for one (1) of three (3) residents reviewed for abuse (Resident #1). Specifically, on 9/23/2025 at approximately 2:00 PM Resident #1's family member reported that Resident #1 alleged sexual abuse, and the allegation was not reported to the New York State Department of Health until 9/24/2025 at 11:18 AM. [...]

Inspectors wroteBased on record reviews, interviews, and observations conducted during an abbreviated (NY00361070, NY00351353) survey, the facility did not ensure that a resident was free from abuse. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2 and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1. As evidenced by: The facility policy for abuse has no date created no indication of ever having been reviewed/revised, and it is not printed on official letterhead. The Policy documents, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. [...]

Inspectors wroteBased on interviews, observations and record review conducted during an abbreviated (NY00361070) survey, the facility did not report incidents of staff to resident abuse to local law enforcement. This was evident for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, Certified Nursing Assistant #1, Certified Nursing Assistant #4, Resident Assistant #2, and Resident Assistant #3 are seen in video footage using more force than necessary to provide care to Resident #1, and those incidents were not reported to local law enforcement. As evidenced by: The facility Policy for abuse has no date, as well as no indication of ever having any updates or reviews it is also noted to not be on any official letterhead. The Policy is written as follows, The Purpose of the Abuse Prevention Program is to ensure a safe, respectful, and dignified environment for all residents. [...]

Inspectors wroteBased on staff interviews and review of facility documentation conducted during an abbreviated (NY00361070, NY00351353) survey, it was determined that the facility did not ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide, based on the outcome of the performance reviews, received no less than twelve hours of in-service education per year. This was evident for 2 of 2 Certified Nursing Assistants (nurse aides) reviewed for completion of performance review and in-service education. Specifically, the facility did not ensure that Certified Nursing Assistant #1 & Certified Nursing Assistant #4 had a performance review at least once every 12 months and based on their individual performance review receive no less than twelve hours of in-service education per year. [...]

Inspectors wroteBased on observation, record review and staff interviews conducted during an abbreviated (NY00351353, NY00361070) survey the facility did not ensure infection control practices to prevent the development and transmission of communicable disease and infection were maintained for 2(Resident #1, Resident #6) of 3 residents reviewed. Specifically,1) Resident #1 was on enhanced precautions, Certified Nursing Assistant #7 and Licensed Practical Nurse #9 were not wearing gowns when they transferred Resident #1 from the bed-chair via Hoyer-lift and Licensed Practical Nurse #9 was not wearing a gown when they stopped Resident #1's G-Tube feeding, clamped the tubing and closed the feeding tube cap. [...]

Inspectors wroteBased on observation, record review and interview conducted during a recertification survey (7/10/23-7/14/23) the facility did not ensure that care was provided in a manner that maintained dignity for 3 of 3 residents (#34, #21, #6). Specifically, Residents #34, #21, and #6's urinary catheter drainage bags were not concealed to prevent direct observation of urine by others.

Inspectors wroteBased on interview and record review conducted during a recertification survey, it could not be ensured that the facility thoroughly investigated an injury of unknown origin for 1 (Resident #118) of 5 residents reviewed for accidents. Specifically, Resident #118 stated they had a burn to their right upper thigh on 6/24/2023 from hot water that was served to them in their own lidded mug, when the nurse who served the hot water did not screw on the top of the mug.

Inspectors wroteBased on observation, record review and interview during the recertification survey from 7/10/2023 to 7/14/2023, the facility did not ensure that 1 (Resident #118) of 5 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, on 6/24/2023 Resident #118 reported they had sustained a right thigh burn after staff provided heated water from the microwave and the facility did not implement interventions for the treatment a skin impairment on the thigh until 6/26/2023. Additionally, the medical provider was unaware the resident had spilled hot water and the blister on the resident's thigh was not identified as a burn, and treated with Silvadene until 6/28/2023 when the nurse practitioner (NP) assessed.

Inspectors wroteBased on observation, record review and interview conducted during the 7/10/23 to 7/14/23 recertification survey it was determined for 1 of 4 residents (Resident #75) reviewed for Activities of Daily Living (ADL) Decline, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion. Specifically, Resident #75 had a Physical Therapy/Occupational Therapy screen on 5/13/23 that recommended restorative nursing that was not ordered until 7/12/23.

Inspectors wroteBased on observation, interview and record review conducted during the recertification survey from 7/10/23 to 7/14/23, it was determined for 1 of 3 residents (Resident # 48) reviewed for Nutrition and Hydration, the facility did not ensure the resident was provided the necessary care to maintain an acceptable body weight. Specifically, when Resident #48 lost 19 pounds the significant weight loss was not addressed by the dietitian for over one month.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey from 7/10/23 to 7/14/23, the facility did not ensure food was prepared, stored, and served in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, 1. a food service worker was observed preparing food without a proper hair restraint, 2. the freezer and refrigerator logs in the meat kitchen were forged and, 3. a large pan of raw chicken was improperly stored.

Inspectors wroteBased on observation, record review and interview during the recertification survey (7/10/23-7/14/23), the facility did not ensure that staff maintained 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. Specifically, 1) During a meal observation two certified nurse aides (CNA) buttered toast using their bare hands before handing the toast to Residents #124 and #26. 2) Housekeeping staff was observed pushing clean linen on an uncovered cart down a hallway. 3) A CNA was observed not using Personal Protective Equipment (PPE) and removed dishes from a resident's room that was on contact precaution, placed the dishes on a food truck, and continued to stack more dishes from the dining room on the food truck without performing hand hygiene.

Inspectors wroteRevised 9/26/2023 IDR Based on observations, interviews and record review conducted during a recertification survey from 7/10/23 to 7/14/23, it could not be ensured that the facility maintained all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, the walk-in freezer door was broken causing excessive frost on equipment, and the ice machine in the dairy kitchen was not maintained in a sanitary manner.

Inspectors wroteBased on observation, interview and record review conducted during the most recent recertification survey, it could not be ensured that the facility provided appropriate care and services for the use of an indwelling catheter (a tube inserted into the bladder to drain urine) for 1 of 4 residents reviewed (Resident # 91). Specifically, the catheter leg bag (to be used when the resident is out of bed) was attached to the resident above the knee while he was lying flat in bed.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility did not ensure that staff followed proper hand hygiene and gloving technique to prevent cross contamination and the spread of infection. Specifically, (1) cross contamination of a wound and wound supplies was observed and proper hand hygiene were not observed during a wound care observation for 1 of 7 residents (Resident #348) (2) soiled linens and diapers were observed in plastic bags on the floor in an occupied resident room on the second floor - [NAME] Side Unit.