Pines Nursing Home

Inspectors wroteBased on observations record review and interview, the facility failed to safeguard and ensure privacy of residents' confidential Electronic Health Records (EHR); as evidenced by one out of two of the facility's medication carts' computer screen was left unlocked and unattended and a physical note posted on two of two medication carts revealing residents' information. There were 44 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR)for individuals with a serious mental illness (SMI), or intellectual disability or related conditions (ID)was completed accurately prior to admission and failed to revise the screenings following admission for three (Resident #13, Resident #8 and Resident#12) out of 20 sampled residents. There were 44 residents residing in the facility at the time of the survey. The findings Included: Resident #13 During observations on 04/27/25 at 08:36 AM, Resident #13 is awake in bed. On 04/28/25 at 07:39 AM Resident #13 was observed in room walking around and stated she is ok, just getting around for the day. Observation on 04/29/25 at 10:23 A; Resident #13 was her room sitting on the side of the bed, conversing with roommate and stated, today is a good day. [...]

Inspectors wroteBased on observations, interview and record review, the facility's Quality Assessment and Assurance (QAA)/QAPI) committee demonstrate effective plan of action were implemented to correct identified quality deficiency in problem areas related to repeated deficient practice for F880-Infection Prevention & Control. As evidenced by: F880 was cited during a Recertification survey ending 12/07/23 when the facility failed to implement infection control procedures. This repeated deficient practice has the potential to affect any of the 44 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement infection control procedures for two Residents (Resident 23 and Resident #34), out of 20 sampled residents. As evidenced by staff failed to dispose used Blood Glucose Monitoring supplies in the sharps container, failed to clean the insulin vial before extracting medications via needle syringe and failed to wear Personal protective equipment (PPE) during catheter care for one ( Resident # 34)out of one resident reviewed indwelling urinary catheter. There were 44 residents residing in the facility at the time of the survey. The findings Included: During a Blood Glucose Monitoring observation on 04/27/25 at 11:08 AM for Resident #34 with Staff A, Licensed Practical Nurse. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (Resident # 47) out of 23 sampled residents. Resident # 47's MDS was coded wrong for a discharge to the hospital, but the resident was discharged home. This deficiency has the potential to affect 45 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure enteral feeding was administered as prescribed and enteral feeding equipment/supplies were dated, labeled and changed daily for one (Resident #12) out of 13 residents receiving enteral tube feeding.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow physician's order for oxygen therapy for one (Resident #36) out of 9 residents receiving respiratory services and to obtain a physician order for oxygen therapy for one (Resident #12) out of 9 residents receiving respiratory services.

Inspectors wroteBased on record review and interview, the facility failed to ensure nine out of ten sampled nursing staff (Staff 1, 2, 3, 4, 5, 6, 8, 9, and 10) received the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had no documentation that the staff received the orientation in-service training including Alzheimer's and Dementia, Abuse, Neglect, and Exploitation.

Inspectors wroteBased on observation and interview, the facility failed to implement pharmacy procedures for recording daily refrigerator temperatures for the refrigerator in the Medication Storage room. There were 45 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the garbage disposal was clean and discarded materials were properly disposed and contained on the facility grounds.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain communication with the hospice provider to ensure continuation of care for 1 (Resident #36) out of 5 residents receiving Hosice services, as evidenced by no updated hospice communication were notes available in Resident #36's medical records, and services provided by Hospice were not coordinated and communicated in the written documentation.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plans of action were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F641 Accuracy of Assessment. The facility failed to accurately code Minimum Data Set (MDS) Section A for one (Resident # 47) out of 23 sampled residents. This deficiency has the potential to affect 45 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement infection control procedures for two (Residents #36, and #198) out of 23 sampled residents. As evidenced by a Licensed Practical nurse (Staff C) not changing gloves during the entire tracheostomy care observation for Resident #36 and not disposing the used Blood Glucose Monitoring supplies in the sharps container. There were 45 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility failed to develop a discharge care plan for one (Resident # 46 ) out of three resident reviewed for discharge care plan at the time of the survey. This deficient practice has the potential to affect 44 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to provide pharmacy services according to the requirements and according to the facility's policy and procedure. This failure had the potential to affect all 44 residents admitted to the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and comfortable environment for one (Resident #9) out of twenty sampled residents, as evidenced by a broken and detached bed rail observed at Resident #9's bedside. There were 44 residents residing in the facility at the time of the survey. The Findings Included: On 10/03/22 at 08:54 AM, Resident #9 was observed in bed awake. Resident #1 stated that the bedrail was broken. The resident reported, it's not fixed, its broken, I need it for my safety. Observation revealed the right-side bed rail leaning on the wall beside Resident #9's bed. On 10/04/22 at 10: 00 AM Resident #9 was observed in bed awake. Resident #1 stated, the staff is aware that the bed rail is broken. Resident #9 could not recall how long her bed rail has been broken and reported it has been a while. [...]

Inspectors wroteBased on record review and interviews, the facility failed to respond to a grievance for one (Resident #5) out of one resident reviewed for grievances. The facility failed to address a concern after Resident #5's wife established communication with the facility's administrator concerning speaking with the doctor about his care. There were 44 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review, interview and observation, the facility failed to develop written Abuse, Neglect and Exploitation policies and procedures. The facility's Abuse, Neglect and Exploitation policy and procedure didn't include components for the investigation, protection and reporting/response. This affected 1 (Resident #15) out of 20 sampled residents. This had the potential to affect all 44 residents admitted to the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to 1. Include in their written Abuse, Neglect and Exploitation policies and procedures the requirement to report crimes occurring in long term care facility, reporting suspicion of crimes to law enforcement immediately, but 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 if the events that cause the suspicion do not result in serious bodily injury. 2. The facility failed to report a suspicion of a crime that resulted in serious bodily harm to 1 (Resident #15) out of 20 sampled residents. This had the potential to affect all 44 residents admitted to the facility.

Inspectors wroteBased on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Residents # 2, Resident # 45 and Resident # 46) out of three resident's MDS assessments reviewed at the time of survey. This deficient practice has the potential to affect 44 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for one( Resident #35) out of one resident PASRR reviewed. This had the potential to affect the 44 residents residing in the facility at the time of the survey. The Findings Included: On 10/03/22 at 08:58 AM, Resident # 35 was observed in room in chair by bed. On 10/04/22 at 10:14 AM Resident #35 was observed in activities during bingo. On 10/05/22 at 02:45 PM Resident #35 was observed standing at the nurse's station conversing with staff, wander alert device noted on left forearm. Review of Resident # 35's Level I PASRR (Preadmission Screening and Resident Review) dated 9/01/22 under Section I: Section I: PASRR Screen Decision Making: A: [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to provide care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, related to dialysis services for one (Resident #32) out of one resident reviewed and two residents receiving in-house dialysis services. Written documentation was not available in the medical records. Services provided by the Dialysis nurse were not coordinated and communicated in written documentation. This practice has the potential to increase the risk of negative resident outcomes and to affect all two in-house dialysis residents residing in the facility at the time of this survey.

Inspectors wroteBased on record review and interview, the facility failed to have the pharmacy consultant conduct medication regimen review at least monthly. This practice has the potential to increase the risk of negative resident outcomes and to affect all twenty-four residents receiving psychoactive medications residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a complete infection control program, as evidenced by no monthly infection surveillance and antibiotic stewardship documentation being available to review electronically or in print. This had the potential to affect the 44 residents residing in the facility at the time of the survey. The Findings Included: Review on 10/4/22 at approximately 4:00 PM with the Director of Nursing (DON) who is also the Infection Control Preventionist (ICP) of a list of Infection Control documentation that would be needed for the infection control interview on the last day of survey. On 10/5/22 infection control documents were requested twice during the time surveyor was at the facility, some documents received. On 10/6/22 the DON wrote down the list of documents needed. [...]