Pine View Manor Inc

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #24 right to be free from abuse when Nursing Assistant (NA) A took a photo of Resident #25 without his/her knowledge and sent it to Certified Nurse Aide (CNA) D using a social media messaging service. The photo showed the resident lying in bed on/his her side with his/her unclothed hip, buttocks, legs and feet exposed. The facility census was 53. Review of the facilities policy Abuse and Neglect Protocol, dated 05/06/26, showed: Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made when the facilities administrator failed to report to the state survey agency and the local police department that Nursing Assistant (NA) A took a nude photo of Resident #25 without his/her knowledge and sent it to Certified Nurse Aide (CNA) D. This affected one of one sampled residents. The facility census was 53. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect one of three sampled residents right to be free from abuse when staff observed Resident #1 and Resident #2 get into a verbal argument, and a short while later, Resident #2 went into Resident #1s room and a physical altercation occurred where both residents were found on the floor. The nurse assessed Resident #1 and found he/she was upset and with physical injuries including a scraped left knee and left elbow and a red mark on the left side of his/her ribs. This affected one of three sampled residents. The facility census was 55. Review of the facilities Abuse and Neglect Protocol policy, dated 2/15/22, showed: -It was the purpose of the facility to prohibit and prevent abuse and to assist the facility staff members in recognizing incidents of abuse; [...]

Inspectors wrote2. Review of the Resident #40's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper extremity and lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use; - Had a Foley catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - The resident had seven antibiotics in the last seven days; - Diagnoses included traumatic brain injury, seizure, dementia and depression. Review of resident's Urinalysis (UA, a test to analyze urine contents) and urine culture and sensitivity ( C & S, at test that identifies the amount and type of bacteria and medications to treat the infection), dated 10/11/24 showed: - The presence of bacteria indicative of a possible urinary tract infection (UTI); - The C & S showed the presence of organisms indicative of a UTI; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed check bed rails regularly to make sure they were still installed correctly as rails may shift or loosen over time. The facility failed to inspect and regularly check the mattress and bed rails for areas of possible entrapment, and failed to include an evaluation of attempted alternatives prior to the installation or use of a bed rail on resident beds. This included three of 12 residents sampled (Resident #1, #33, and #34). The facility census was 48. Review of facility policy, side rail policy/ grab bars, revised 5/21/25, showed: -Facility would strive to provide a safe sleeping environment for all residents. -If resident wanted or needed side rails the MDS Coordinator or Nursing would contact the physical therapy department. [...]

Inspectors wroteBased on observation, interview, and record review, and the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep all hair contained in hair restraints, failed to label and date food when it was opened, and failed to complete temperature checks on the refrigerator and freezers. This had the potential to impact all residents in the facility. The facility census was 48. 1. Review of facility policy, Hair Restraints, dated 5/29/24, showed: -Hair restraints shall be worn by all dietary staff when in food production areas, dishwashing areas, or serving food. -Staff shall wear hair restraints in all food production, dishwashing, and serving areas. -Hair restraints, such as hairnets, hats, hair bonnets, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair was discouraged. [...]

Inspectors wrote3. Review of Resident #40's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper extremity and lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use; - Had a Foley catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - The resident had seven antibiotics in the last seven days; - Diagnoses included traumatic brain injury, seizure, dementia and depression. Review of the resident's Physician Order Sheet (POS), dated May 2025, showed: - Foley catheter for urinary retention. Review of the resident's undated care plan, showed: - The resident had an indwelling Foley catheter for bladder retention; - The resident had a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain professional standards in the kitchen. Specifically, the facility failed to ensure dented canned foods were not in circulation in 1 of 1 dry storage area observed. This had the potential to affect all 55 residents who resided in the facility and received meals from the kitchen.

Inspectors wrote2. A facility policy titled, Oxygen Administration, revised in 10/2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration; however, the policy did not address infection control measures for labeling or storage of oxygen equipment/supplies. During an interview on 05/31/2024 at 12:20 PM, the Director of Nursing Services (DNS) stated that night shift staff should change oxygen tubing once per week. The DNS stated the tubing should be labeled and stored in a blue bag. An admission Record revealed the facility admitted Resident #3 on 06/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of pneumonia and heart failure. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #5) of 1 sampled resident reviewed for self-administration of medications was assessed to determine if they were clinically appropriate to do so after the resident expressed a desire to self-administer one of their medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a care plan addressing the use of as needed, supplemental oxygen for 1 (Resident #3) of 3 sampled residents reviewed for respiratory care.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure only licensed personnel adjusted the flow rate on an oxygen concentrator for 1 (Resident #45) of 3 residents reviewed for supplemental oxygen use.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to specify dose parameters for 1 (Resident #7) of 3 residents reviewed for supplemental oxygen use. Specifically, the facility failed to ensure Resident #7's supplemental oxygen orders specified liters per minute (L/min) parameters.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #50) of 5 residents reviewed for unnecessary medications was free of significant medication errors. Specifically, staff administered metoprolol tartrate (a medication used for high blood pressure) to Resident #50 despite the resident's blood pressure being below the ordered parameters for administration and without monitoring the resident's pulse.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medication was safely stored for 1 (Resident #5) of 1 sampled resident reviewed for self-administration of medication. Specifically, Resident #5 had an order to keep their Flonase nasal spray at the bedside; however, the facility failed to ensure the medication was stored in a safe and secure place, not accessible to other residents, as directed by the facility's policy.

Inspectors wroteBased on interview, record review, and review of the Facility Assessment Tool, the facility failed to ensure nurse aides received 12 hours of required in-service training per year for 2 (Certified Medication Technician [CMT] #3 and CMT #10) of 5 nurse aide employee files reviewed.

Inspectors wroteBased on interview and record review, the facility staff failed to report to Department of Health and Senior Services (DHSS) an injury of unknown origin when the facility staff became aware on 12/14/23 that one resident (Resident #1) had a broken femur and did not know the source of the fracture. The facility census was 54. Review of facility policy, Abuse and Neglect Protocol, dated 2/15/22, showed: -Response and Reporting: It is the purpose of this facility to report to the state agency and appropriate law enforcement entity, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility. The facility shall report not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours. Serious bodily injury would be classified as a fracture. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered plan of care which included measurable objectives and timeframe's to meet each resident's medical, nursing, and mental psychosocial needs identified in the comprehensive assessment for of three of 13 sampled residents (Residents #2, #22 and #30). The facility census was 51. Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, showed the following: - A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a fall plan for one of 13 sampled residents who was at risk for falls, had multiple falls and a recent fall with an injury (Residents #30). The facility census was 51. Review of the facility policy Fall Protocol and Management dated 4/15/22 showed: -The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall and implementing interventions to prevent falls. 1. Review of Resident #30's Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff) dated 4/27/22, showed: - A Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment; - Diagnoses of : [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, and failed to review the risks and benefits with the resident or resident representative and failed to obtain informed consent from resident or resident representative. This affected three of 13 sampled residents (Residents #22, #47, and #50). The facility census was 51. Review of the pamphlet titled A Guide to Bed Safety, dated October 2000, included: - Which ways of reducing risk are best: o A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety. Many patients go through a period of adjustment to become comfortable with new options. Patients and their families should talk to their health care planning team to find out which options are best for them; [...]