Pine View Nursing and Rehab Center

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation, the facility failed to protect one of seven residents' (R11) right to be free from physical abuse from a resident (R10). Actual harm was identified to have occurred on 05/12/2026 when R10 struck R11, causing maxillary sinus and orbit fractures and lacerations to R11's face and scalp.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to ensure care plan interventions were implemented for one of 16 sampled residents (R) (R16). This deficient practice had the potential to place R16 at risk of falls and unmet care needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Nutrition Policy, the facility failed to properly prepare pureed food and ensure nutritive value for eight of eight residents receiving a pureed diet. This failure had the potential to serve food at a lesser nutritive value that could cause weight loss.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Food Safety and Sanitation, the facility failed to ensure that food was stored in a manner that prevented foodborne illness to the residents, failed to ensure the food was stored at the appropriate temperatures and failed to ensure that dishes and utensils were cleaned under proper sanitary conditions. The deficient practices had the potential to place all residents at risk of acquiring foodborne illnesses. There were 104 residents who received an oral diet from the kitchen.

Inspectors wroteBased on record review, and staff interviews, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility failed to Maintain and/or produce documentation that demonstrates evidence of its ongoing QAPI program. The deficient practice had the potential to affect resident care outcomes and quality of life for 109 residents.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Administering Medications, the facility failed to ensure that the medication error rate was less than five percent (%) for one of three residents (R) (R79) observed during medication administration. There were 26 opportunities observed for three residents with ten errors resulting in an error rate of 38.46 %.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Administering Medications, the facility failed to ensure that medication was administered according to physician's orders for one of three residents (R) (R79) observed during medication administration. Specifically, R79 received medications by mouth when she should have received the medication through her G-tube (gastrostomy tube). This deficiency had the potential to cause R79 to aspirate which could have led to physical harm or hospitalization.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policies titled, Hand Hygiene and Legionella Surveillance, the facility failed to ensure staff performed proper infection control practices while serving meals to the residents on two of five halls (D Hall and E Hall). In addition, the facility failed to ensure an effective water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. The deficient practices had the potential to spread infection by cross-contamination and placed the residents at risk of waterborne illnesses, including Legionnaires disease. The facility census was 97 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Environment, the facility failed to provide a safe, functional, sanitary, and comfortable environment on three of five halls and one of two shower rooms. These deficient practices had the potential to place residents at risk of living in an unsanitary living environment and a potential for diminished quality of life. The facility census was 97 residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Bedside Medication Storage, the facility failed to ensure unauthorized medications were not stored at the bedside for one of 40 sampled residents (R) (R10). This deficient practice had the potential to place R10 at risk of the use of unauthorized medications in an unsafe manner. Findings Include: A review of the facility's policy titled, Bedside Medication Storage, revision date 8/2020, revealed the Policy section stated, Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team (or equivalent). The Procedures section included 1. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Bed Hold Policy, the facility failed to provide written bed hold notices for one of three residents (R) (R201) reviewed for hospitalization. This failure had the potential to place R201 at risk of possible denial of re-admission and loss of their room following a transfer to the hospital.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's status at the time of the assessment for one of 40 sampled residents (R) (R42). This deficient practice had the potential to affect the assessment of R42's care needs. Findings Include: A review of R42's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. A review of R42's Annual MDS dated [DATE] revealed Section A (Identification Information) documented the resident had not been evaluated by Level II PASRR [Preadmission Screening and Resident Review] and determined to have a serious mental illness and/or mental retardation or a related condition. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to ensure activities of daily living care, specifically fingernail care and oral hygiene, were provided for two of 40 sampled residents (R) (R11 and R2). The deficient practice had the potential to place R11 and R2 at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Controlled Substance Prescriptions, the facility failed to ensure controlled medication shift counts were documented with nurse signatures on one of four medication carts (D Hall Medication Cart). This deficient practice had the potential to affect the availability of residents' controlled medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from one of two medication storage rooms. The deficient practice placed residents at risk of receiving expired medications. The facility census was 97 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Sanitation Inspection and Date Marking for Food Safety, the facility failed to ensure that opened food items in the dry storage area were dated with the open date and expiration date, pots and pans were not facing outward, the dishwasher was free of spilled detergent, the freezer floor was free of rust, the stove was free of spills and stains, and the kitchen floor was clean. The deficient practice had the potential to affect 93 of 99 residents receiving an oral diet.

Inspectors wroteBased on observation, staff interviews, and review of the facility policies titled, Maintenance Inspection and Housekeeping Services, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in six of 61 resident rooms (rooms D4, D6, D8, D9, D12, and D13) on one of five hallways (D Hall) related to grime build-up on room air conditioner (AC) units, dust build-up on room AC unit filters, and an area of missing and uneven flooring.

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Restraints, Physical and Restraints, Consent For Use, the facility failed to ensure three of 27 sampled Residents (R) (R#7, R#18, and R#80) were free from the use of physical restraints. Specifically, geri-chairs (reclining, geriatric chair) with tray tables secured to the front of the chairs and wedges put underneath mattresses to raise them up were used, preventing R#7 and R#18 from getting up from the geri-chair and R#80 from getting out of the bed.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to submit an application for a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 27 sampled residents (R) (R#73).

Inspectors wroteBased on observations, staff interviews, and review of facility's policy titled, Comprehensive Care Plan, the facility failed to follow the care for three of 27 sampled residents (R) (R#7, R#18, and R#80) related to the use of a restraint.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Tracheostomy Care, the facility failed to ensure the provision of respiratory services in accordance with professional standards for one of two residents (R) (R#74) reviewed for tracheostomy (trach) care. Specifically, the facility failed to include one size as ordered, and one smaller tracheostomy tube in emergency tracheostomy supplies at bedside. This failure increased R#74's risk for compromised airway/respiratory distress.