Pine View Care Center

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a resident area remained at a safe, comfortable, and home-like temperature for 4 of 4 residents (R) (R1, R2, R3, R4) reviewed. On 07/16/26, the facility's Heating, Ventilation, and Air Conditioning (HVAC) cooling system on the 100 unit where R1, R3, R4 resided, and 300 unit where R2 resided stopped working which resulted in room temperatures that were above 81 degrees Fahrenheit (F). Common areas throughout the building exceeded 81 degrees F.This is evidenced by: On 07/16/26 at 10:45 AM, the outside temperature was 82 degrees F with a feel like temperature of 85 degrees F. On 7/16/26 at 9:12 AM an air quality alert was in effect for [NAME] County until noon on 7/17/26 according to La [NAME] Wisconsin National Weather Service. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure dietary staff had the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. This had the ability to affect all 32 residents. Facility Cook's son, who is not an employee of the facility, was assisting with kitchen duties. The Division of Quality Assurance received concerns indicating [NAME] C was taking pictures in the facility kitchen and posting them on social media on 03/30/26 and photo evidence was provided. The photo contained a caption that read, Thank you Jesus for my son coming to work with me through this dbl . to help his mom out!! . The post showed identified son handling beverages. Surveyor reviewed [NAME] C's social media page and confirmed the photos and captions were still present and open to the public. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents have a right to be treated with respect and dignity, for 1 (R8) of 5 residents reviewed for resident rights. Certified Nursing Assistant (CNA) H searched through and removed items from R8's purse without permission while R8 was out of the room.

Inspectors wroteBased on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated which involved 2 (R6 and R7) of 7 residents reviewed for abuse. The facility did not implement immediate interventions, update care plans, or complete monitoring in relation to a resident-to-resident physical altercation between R6 and R7.

Inspectors wroteThe facility did not revise 1 (R8) of 12 comprehensive care plans and include person-centered, comprehensive interventions. R8's comprehensive care plan was not updated with person centered interventions.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (R9) of 3 residents reviewed for accidents. The facility staff did not follow R9's care plan for transfer status. R9 is a Hoyer lift and staff utilize the sit-to-stand mechanical lift for transfers.

Inspectors wroteBased on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident or contacting the provider when a resident's medication(s) is not available for administration for 1 of 4 residents (R3). R3 was noted to have not received scheduled doses of ASA (aspirin), Bupropion, Famotidine, Fluticasone salmeterol inhaler, Amitriptyline, and Duloxetine. The facility policy titled Medication/Treatment Administration Error Policy last revised on 04/25, states: Protocol (1)(b): A facility medication/treatment error occurs when a prescribed medication is not available to be administered. Protocol (2)(f) A pharmacy medication error occurs when: a drug is unavailable from the pharmacy that the physician prescribed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident or contacting the provider when a resident's medication(s) is not available for administration for 1 of 4 residents (R3). R3 was noted to have not received scheduled doses of Xarelto (anticoagulant) and Amiodarone. The facility policy titled Medication/Treatment Administration Error Policy last revised on 04/25, states: Protocol (1)(b): A facility medication/treatment error occurs when a prescribed medication is not available to be administered. Protocol (2)(f) A pharmacy medication error occurs when: a drug is unavailable from the pharmacy that the physician prescribed. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions to prevent accidents for 1 of 2 observations of resident (R)(R3) transfers. R3 was observed transferred by CNA D independently using lift equipment. This is evidenced by:Facility policy titled, Body Mechanics - Transfer Training, with a reviewed date of 11/2024, states in part: Purpose: To provide direction to nursing staff members for training of appropriate body mechanics and safe resident transfer techniques. Protocol: 1. Key Points: b. Reminder that for mechanical sit-to-stand use and mechanical full body lift use, two CNAs, licensed nurse staff or therapists are required to perform the transfer/lift. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 3 residents (R)(R3) reviewed for insulin administration. R3 did not have 2 doses of sliding scale insulin administered per physician order on 02/28/26 and 03/15/26 based on blood sugar result. This is evidenced by:Facility policy titled, Diabetic Blood Sugar Monitoring, with a reviewed date of 11/2022, states in part: Purpose: It is the policy of this facility that blood sugars will be measure and recorded on diabetics per physician orders or when symptomatic. Protocol: 5. If ordered, give sliding scale insulin as ordered by physician. R3 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus without complications. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect 1 of 3 residents (R1) right to be free from verbal abuse by a Certified Nursing Assistant (CNA). CNA G (Certified Nursing Assistant) was observed to be swearing at and treating R1 roughly when assisting with needs. Evidenced by:The facility policy titled Resident Safety Abuse Policy last reviewed 3/2024 states in part It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property. Providing a safe environment is one of the most basic and essential duties of the facility. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the policy and procedures that prohibit mistreatment, abuse, and neglect of residents were implemented for 2 of 3 residents (R1 and R2) reviewed for abuse. The facility did not implement their abuse policy and procedure as the facility did not report allegations of abuse to the State Agency, did not fully investigate allegations of abuse or put measures in place to protect residents while an investigation was occurring for abuse allegations involving R1 and R2. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 2 of 3 residents (R1and R2) reviewed for abuse allegations. A facility staff member reported an allegation of abuse regarding R1 that was not reported to the State Agency or police. R2's family member reported an allegation of abuse that was not reported to the State Agency or police. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. [...]

Inspectors wroteBased on interview, and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 2 of 3 residents (R1 and R2) reviewed for abuse. A facility staff member reported an allegation of abuse regarding R1 that was not thoroughly investigated. R2's family member reported an allegation of abuse that was not thoroughly investigated. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 or 3 residents (R3) reviewed for transfers. R3 was transferred using a sit-to-stand mechanical lift instead of a full body mechanical lift. This is evidenced by:The facility's policy Body Mechanics-Transfer Training, dated 11/24, includes: To provide direction to nursing staff members for training of appropriate body mechanics and safe resident transfer techniques. ii. If the resident has no ability to sit, stand, or bear weight, DON'T LIFT - use a mechanical assist. R3 admitted to the facility on [DATE]. R3 has a right below the knee amputation. R3's comprehensive care plan includes: 11/12/25 Transfer assist: Full body lift assist of 2. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility did not follow proper food handling practice to prevent foodborne illness. This had the potential to affect all 30 residents residing in the facility. Surveyor observed staff touch ready to eat foods with contaminated gloves.

Inspectors wroteBased on interview and record review, the facility did not formulate an advance directive for the resident. Resident (R) 185 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 13 residents surveyed (R185).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This affected 1 of 4 residents (R17) observed for medication administration. R17 received two insulin injections by using injectable pens that a safety check was not completed on to ensure the injectable pens were dispensing insulin before administration.

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. The facility did not ensure that potentially hazardous foods were served at temperatures that would reduce the chance of illness for residents. The facility did not cover food while transporting room trays past resident rooms and in hallways. This has the potential to affect 2 residents (R) (R1, R12) on a pureed diet and 3 of 8 residents (R6, R17, R5) receiving room trays.

Inspectors wroteBased on observation, interview and record review, the facility did not assist 1 of 13 sampled and supplemental residents (R19) with eating in a dignified manner by scooping food from her lip and chin with a spoon and feeding it to her. This is evidenced by: Surveyor requested and received the facility policy titled Meal Service Standards which is dated as last revised on 12/18. The policy in part reads: Purpose: The following meal service standards will ensure our residents have a safe, pleasant and enjoyable dining service. Protocol: 1. Dignity: h. All residents are served in a dignified and courteous manner. Surveyor reviewed R19's record and noted the following: The most recent quarterly Minimum Data Set (MDS) completed 12/28/24 notes R19 is dependent on staff to eat. [...]

Inspectors wroteBased on observation, record review and interviews, the facility did not ensure that 1 of 3 sampled and supplemental residents (R) who are unable to carry out activities of daily living received the necessary services to maintain good nutrition (assistance with meals). (R9)

Inspectors wroteBased on record review and interview, the facility did not comprehensively assess 1 of 2 residents (R31) for trauma informed care and care plan approaches to mitigate any triggers to prevent re-traumatization. This is evidenced by: Surveyor requested and received the facility policy titled Providing Culturally Competent and Trauma-Informed Care dated as most recently revised on 8/22. The policy in part reads: Purpose: Residents who are trauma survivors will receive culturally competent, trauma informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Protocol: 1. Assessment: a. A multi-faceted approach to identifying resident history of trauma as well as his or her cultural preferences will be utilized. [...]

Inspectors wroteBased on observations and interviews, the facility did not provide pharmaceutical services to meet the needs of 1 of 1 resident reviewed for insulin administration (R31). This is evidenced by: The Bureau of Quality Assurance issued a memo dated 9/23/2003 (Memo number 03-014) which states that insulin is classified into five categories: Rapid-acting, Short-acting, Intermediate-acting, Long-acting, and Combination products. The memo points out that Rapid-acting, Short-acting, and Combination products start working within a short time frame and are meant to control blood sugar levels at meals. The memo states that it is important that the meal and administration of the insulin are properly timed to optimize blood sugar control. The memo also states that rapid-acting insulins (Novolog and Humalog) should be administered 0-15 minutes before meals or immediately following a meal. [...]