Pine Village

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness.

Inspectors wroteThe facility had a census of 66 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to use appropriate barriers while sorting soiled laundry. This placed the residents at risk of infectious diseases.

Inspectors wroteThe facility had a census of 66 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 30. This placed the resident at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents. Based on record review and interview, the facility failed to complete performance reviews of all nurse aides, provide regular in-service education based on the outcome of these reviews, and ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 71. This placed the resident at risk for missed care opportunities.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents of which 10 were reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when the facility failed to assess Resident (R)16 for safe use of an electric recliner. This placed the R16 at risk for injury due to preventable accidents and hazards.

Inspectors wroteThe facility had a census of 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)19, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and related side effects.

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide one of the sampled residents, Resident (R) 115 (or their representative) the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123 Centers for Medicare and Medicaid Services (CMS), and the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNF ABN) Form 10055 .

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents, with one reviewed for Pre-admission Screening and Annual Resident Review (PASARR). Based on observation, interviews, and record review the facililty failed to ensure a referral was made promptly by the nursing home to the state PASARR program for a Level 2 Resident Review for Resident (R) 63 who had a documented a mental illness (MI) or intellectual disability (ID).

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to follow toileting and fall interventions as directed in the resident's plan of care care for one sampled resident, Resident (R) 29, who had several falls.

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to accurately assess Resident (R) 5's side rails for safe use, placing R5 at risk for accident and injury.

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure appropriate diagnoses for the use of antipsychotic medications (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental illness conditions) for three sampled residents, Residents (R) 9, R29 and R14. This placed the residents at increased risk for inappropriate treatment and risk for adverse outcomes associated with antipsychotic medications