Pine View Center

Inspectors wroteBased on observation and staff interview the facility failed to serve food in a sanitary condition. This practice had the potential to afffect all residents receiving food from the kitchen area. Facility census: 47.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for residentsin room [ROOM NUMBER], #312, and #313 . This was a random opportunity for discovery and had the potential to affect a limited number ofresidents. Facility census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. This was a random opportunity discovered during the completion of the Beneficiary Notification pathway throughout the Long-Term Care Survey Process. Resident Identifier: 57. Facility Census: 47.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible This failed practice was a random opportunity for discovery and had the ability to effect a limited number of residents Facility Census:47Finding Included: a) Resident Sitting room: During a facility walkthrough, the surveyor observed the following in the sitting room wall near the nurses' station: Loose, crumbling sheetrock pieces were falling from the wall onto the floor under the left side of the window. This area was easily accessible to residents. In an interview with Employee # 46 Licensed Practical Nurse(LPN) on 04/20/25 at 12:45AM, she acknowledged the crumbling sheet rock chunks falling .from the wall and onto the floor, stated she blocked it off and said she would notify the maintenance department. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain accurate records for two (2) of two (2) Hospice residents sampled throughout the Long-Term Care Survey Process. Resident identifiers: #44 and #6. Facility census: 47.

Inspectors wroteBased on observation, staff interviews, and resident interviews, the facility failed to ensure an effective pest control program was in place. This was random opportunity for discovery with the ability to effect a limited number of residents. Room identifiers: #310, #312, and #313. Facility census: 47.

Inspectors wroteBased on interviews and record review, the facility failed to provide privacy for visitation. This is true for one (1) of one (1) resident reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1, #40. Facility census: 47. Findings Included: a) Resident #1 On 10/29/24 at 10:55 AM during an interview with Resident 1's Medical Power of Attorney, she stated that all Resident 1's visitor's including her, have issues with Resident #40 opening the door, cursing the visitors and trying to come into the room. A record review on 10/29/24 of grievances revealed no grievance form was filled out for these issues. A medical record review of progress notes revealed multiple occasions 10/22/2024 3:35 PM A note stated Resident #1's sister came to a nurse and stated Resident #40 came to resident's room opened the door and just laughed then left at 3:05 PM and 3:15 PM. [...]

Inspectors wroteBased on interview, record review and policy review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of two (2) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #1 and #5. Facility census: 47.

Inspectors wroteBased on observation, staff interview and record review, the facility failed to store and label food in accordance with professional standards for food service storage. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #146. Facility census: 47.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to the resident and the long-term care Ombudsman for one (1) of two (2) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #27. Facility census: 47.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Bed Hold notice for an acute hospital transfer. This was true for two (2) out of two (2) residents reviewed under the hospitalization pathway in the annual Long-Term Care Survey Process. Resident identifiers: #27, and #16. Facility census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with newly evident or a possible serious mental disorder. This was true for two (2) out of two (2) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifiers: #6 and #28. Facility census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of 24 residents reviewed in the Long-Term Care Survey process. The facility failed to address Resident #145's preferred bedtime preference. Facility identifier: #145. Facility census: 47.

Inspectors wroteBased on Interview and record review, the facility failed to contact the physician; and request a re-assessment of resident's capacity; after a Brief Interview for Mental Status (BIMS) evaluation revealed severe impairment. Resident identifiers: #18. Facility census: 47.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to follow physician orders regarding oxygen administration, and did not monitor residents on oxygen therapy as prescribed. Resident identifiers: #5, and #11. Facility census: 47.

Inspectors wroteBased on resident representative interview, record review, and staff interview, the facility failed to collaborate with resident trauma survivors, and as appropriate, the resident's family, to identify triggers which may re-traumatize the resident, and develop care plan interventions to minimize or eliminate the effect of the trigger on the resident. This was true for one (1) of two (2) residents reviewed with a Post Traumatic Stress Disorder (PTSD) diagnosis. Resident identifier: #27. Facility census: 47.

Inspectors wroteBased on personnel file record reviews review and staff interview, the facility failed to provide a completed performance review of every nurse aide at least once every 12 months. This failed practice had the potential to affect more than a limited number of residents. Employee identifiers: #49, #5. Facility census: 47.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the consulting pharmacist performed a medication regimen review, which included a review of the resident's medical record, at least monthly. This was true for two (2) of five (5) residents reviewed under the unnecessary medication's pathway throughout the Long-Term Care Survey Process. Resident identifiers: #27 and #28. Facility census: 47. a) Resident #27 A record review, completed on 10/29/24 at 1:33 PM, revealed there was no evidence in the electronic medical record that a monthly medication regimen review had been completed for Resident #27 during the months of November 2023 and December 2023. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate care plan was developed for four (4) of 14 residents reviewed in the long-term care survey sample. For Residents #13 and #20, the care plan was not developed for psychotropic medication. For Resident #7, the care plan was not developed for psychotropic medication and dementia care. For Resident #4, the care plan was not developed for Post-Traumatic Stress Disorder. Resident identifiers: #13, #20, #7, #4. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the physician identifed and reported medication irregularities for Residents #13, #20, and #7. Additionally, the physician failed to respond to the pharmacist's reported irregularity for Resident #9. These deficient practices had the potential to affect four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #13, #20, #7, #9. Facility census: 24.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the required members attended the 4th quarter Quality Assessment and Assurance (QAA) meeting. This had the potential to affect more than a limited number of residents at the facility. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to develop policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. This deficient practice had the potential to affect more than a limited number of residents eligible to receive pneumococcal vaccination. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the physician's orders correctly conveyed the resident's/resident's representative's wishes regarding end of life treatment for two (2) of 14 residents reviewed for the care area of advance directives. Resident identifiers: #223 and #125. Facility census: 24.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure water temperatures were comfortable for bathing activities. This was a random opportunity for discovery. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of discharge had a discharge planning process in place, involving the resident, which addressed the resident's discharge goals and needs. Resident identifier: #22. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a discharge residents recapitulation of stay, which included the course of treatment at the facility. This was true for one (1) of one (1) resident reviewed for the care area of discharge during the long-term care survey process. Resident identifier: #22. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to administer a medication used to treat high blood pressure per the physician's orders for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier #7. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that residents who are trauma survivors receive trauma-informed care in accordance with professional standards of practice. This was true for one (1) of two (2) residents reviewed for the care area of mood and behavior. Resident identifier: #20. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medications was free from antipsychotic medication use. Resident identifier: 7. Facility census: 24.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medications in the medication storage room were stored and labeled in accordance with currently accepted professional principles. One (1) vial of insulin was not dated to indicate when opened. Additionally, several medications in the intravenous cart were past the manufacturer's expiration date. Facility census: 24. a) Medication storage and labeling On 01/04/23 at 8:45 AM, inspection of the medication storage room was conducted with Licensed Practical Nurse (LPN) #43 in attendance. The refrigerator in the medication storage room contained a vial of insulin that had not been dated when opened to indicate when the insulin should be discarded. LPN #43 stated she thought the insulin had been opened last night, but confirmed the vial was not dated. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident's Physician Orders for Scope of Treatment (POST) were complete and accurate. This was discovered for two (2) of 14 POST forms reviewed during the Long Term Care Survey Process. The POST forms for Residents #18 and #4 were incomplete. Resident identifiers: #18 and #4. Facility census: 24.