Pinewood Health and Rehabilitation

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain the outdoor garbage and refuse area in a sanitary condition. One of two dumpsters was observed with the lid left open, creating the potential to attract and harbor pests and insects. The facility census was 63.

Inspectors wroteBased on the record review, staff interviews, and review of the facility's policies titled Abuse, Neglect and Exploitation, and Notification of Changes, and review of procedures titled Foley Irrigation Procedure, the facility failed to ensure two of three Residents (R) (R1 and R2) received the necessary care and services in accordance with physician orders. In addition, the facility also failed to ensure the physician was notified in a timely manner of significant changes in the resident conditions. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on [DATE], at 2:23 pm. [...]

Inspectors wroteBased on record review, staff interviews and review of the facility's policy titled Comprehensive Care Plan, the facility failed to implement care plan interventions for two of three Residents (R ) (R1 and R2). Specifically, R1 was prescribed antiplatelet medication and had care plan interventions that included monitoring and documenting adverse outcome. In addition, R2 had a care plan for obstructive uropathy and an indwelling Foley catheter with care plan interventions to provide catheter care. On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy titled Incidents and Accidents, the facility failed to ensure one of one Hoyer lifts to transfer 13 residents was functional and free of defective parts. Specifically, the facility failed to remove a malfunctioned Hoyer lift and to ensure that it was properly repaired prior to the residents' use and the purchase of a new Hoyer lift. On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on October 4, 2025. [...]

Inspectors wroteBased on record review, staff interview, and the facility job description for the former Administrator and Director of Nursing, the facility failed to provide administrative oversight to ensure physician orders were obtained and implemented as written and failed to ensure adequate supervision of the quality of care was provided for two of three Residents (R) R1 and R2. On March 3, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing (DON), Assistant Direction of Nursing (ADON) were informed of the Immediate Jeopardy (IJ) on March 3, 2026, at 2:23 pm. The noncompliance related to the IJ was identified to have existed on October 4, 2025. [...]

Inspectors wroteBased on records review, staff interviews, and the facility policy titled Fall Prevention Policy, the facility failed to ensure that one Resident (R1) with a history of multiple falls and receiving Plavix daily had accurate and complete neurological checks for a head injury on [DATE] and a second fall on [DATE] resulting in an acute bilateral tentorial subdural hemorrhage to the left side of the head with a right-to-left midline shift. The resident expired on [DATE] with an immediate cause of death determined to be a subdural hematoma. The facility census was 60. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, staff interviews, the facility failed to ensure that staff nurses assessed and completed neurological checks for one of 10 Residents (R1) who had a fall (5/15/2025) with a head injury and sustained a hematoma. The census was 60. On August 12, 2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing, Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on August 12, 2025, at 4:07 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on May 15, 2025. An Acceptable IJ Removal Plan was received on 8/14/2025. [...]

Inspectors wroteBased on record review, staff interviews, and a review of the facility-provided Administrator and Director of Nursing (DON) Job Description, the Administration failed to provide oversight and supervision related to assessments of post fall monitoring and neurological checks by licensed nurses and failed to ensure safety measures implemented were effective for R1, who suffered head trauma after a fall, resulting in death. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Interim Director of Nursing (DON), Director of Nursing, MDS (Minimum Data Set) Coordinator, and Registered Nurse Wound Care were informed of the Immediate Jeopardy on [DATE], at 4:07 p.m. [...]

Inspectors wroteBased on record review, staff and resident interviews, and review of the facility policy titled Documentation in Medical Record, the facility failed to ensure the medical record documentation was complete and accurate for one of 10 sampled residents (R) (R5). Specifically, staff documented the presence of maggots between the left great toe and the second toe for R5.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food in refrigeration and freezer storage, failed to discard food in refrigeration storage with expired use by dates or signs of spoilage, and ensure scoops were not stored in containers of sugar, flour, and corn meal. The facility also failed to keep the kitchen's oven, large manual can opener, and metal exhaust hood vents clean. This failure had the potential to create an environment for food-borne illnesses which could affect 57 of 57 residents who consumed food prepared from the facility's kitchen.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement interventions to aid in the healing of pressure ulcers for two of two residents (Resident (R) 45 and R48) reviewed for pressure ulcers out of a total sample of 21. This had the potential to cause delay in the healing of the residents' pressure ulcers.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a resident's wish for a Do Not Resuscitate (DNR) code status as specified in the resident's Physician Orders For Life-Sustaining Treatment (POLST, this is a Physician's Order guided by the patient's medical condition and based upon personal preferences verbalized to the physician or expressed in an Advanced Directive) was ordered and accurately documented in the resident's medical record for one of two residents (Resident (R) 54) reviewed for advanced directives in a total sample of 21 residents. This failure created the potential for residents not to have their wishes followed should they suffer a health emergency.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for two of three residents (Resident (R) R7 and R41) reviewed for hospitalization. The failure had the potential to affect the residents and/or their representative concerning the resident's appeal rights.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to implement the comprehensive plan of care for one resident ((R) 29) of three residents reviewed for nutrition out of 21 sampled residents. The facility's failure to assist R29 with meals as indicated in the resident's plan of care placed R29 at risk for weight loss and nutritional complications.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to review and revise the care plan for one of two residents reviewed for care plans (Resident (R) 48). R48's care plan was not revised to reflect repositioning and/or limiting the resident's time in her wheelchair per the physician's order. This failure placed the resident at risk for unmet care needs and worsening of a pressure ulcer.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide eating assistance for one of three residents (Resident (R) 29) reviewed for nutrition out of 21 sampled residents. This failure had the potential to cause weight loss and/or nutritional complications for this resident.

Inspectors wroteBased on interview and record review, the facility failed to report abnormal blood sugar levels to the physician for one of two residents reviewed for laboratory services (Resident (R)32). This deficient practice could lead to serious health complications for R32 such as nerve damage, kidney disease, vision problems, heart disease, and even diabetic coma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document in the medical record that insulin was not administered when blood sugars were 250 ml/dl (milligrams per deciliter) or less for one (Resident (R)32) of one resident reviewed for resident records. The failure had the potential to result in overlooking proper care and diabetic complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to include in the binding arbitration agreement that it was not a requirement to sign the agreement to continue to receive care at the facility and be allowed to communicate with federal, state, local officials and the ombudsman for two of three residents (Resident (R)32 and R42) reviewed for arbitration out of 21 sampled residents. This placed residents at risk of unknowingly giving up their constitutional rights.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the arbitration agreement provided for the selection of a neutral arbitrator and a venue without stipulations for two (Residents (R)32 and R42) of three residents in a sample of 21 reviewed for arbitration. This placed residents at risk of an unfair advantage in the selections of venues and arbitrators.

Inspectors wroteBased on interview, record review, policy review, and review of the Centers for Disease Control website, the facility failed to offer pneumococcal vaccinations to two of five residents (Resident (R)1 and R45) reviewed for immunizations out of a total sample of 21. This placed the residents at risk of acquiring pneumonia/pneumococcal infections.

Inspectors wroteBased on staff interviews, record reviews, and a review of the facility's policies titled Abuse Prevention Policy & Procedure and Identifying Sexual Abuse and Capacity to Consent policy, the facility failed to protect Resident (R) 4's right to be free from sexual abuse by R5. The facility sample size was 21. On 8/8/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. [...]

Inspectors wroteBased on staff interviews, record reviews, and review of the policy titled Abuse Prevention Policy & Procedure, the facility failed to ensure that allegations of abuse or injury of unknown origin were reported to the State Survey Agency in a timely manner for four Residents (R) (R4, R5, R3, and R8), failed to ensure that an allegation of sexual abuse involving two residents (R4 and R5) was reported to law enforcement in a timely manner, and failed to ensure that the initial and follow up reports to the State Survey Agency, for an allegation of sexual abuse involving two residents (R4 and R5), contained complete and accurate information, from a total sample of 21 residents. [...]

Inspectors wroteBased on interviews, record reviews, and review of the Abuse Prevention Policy & Procedure, the facility failed to conduct an investigation and implement protective measures in a timely manner following an allegation of resident-to-resident sexual abuse involving two Residents (R) (R4 and R5) from a total sample of 21 residents. On 8/8/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. An Acceptable IJ Removal Plan was received on 8/15/2024. [...]

Inspectors wroteBased on interviews, record reviews, and review of the job descriptions for Nursing Home Administrator and Director of Nursing (DON), facility Administration failed to ensure that all components of the facility's abuse prevention system were implemented in a thorough and timely manner to address allegations of abuse or injury of unknown origin for four Residents (R) (R4, R5, R3, and R8), from a total sample of 21 residents. On 8/8/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Minimum Data Set (MDS) Nurse, and Regional Director of Operations were informed of the Immediate Jeopardy (IJ) on 8/8/2024 at 11:25 am. The noncompliance related to the IJ was identified to have existed on 7/7/2024. [...]

Inspectors wroteBased on observations, record review, staff interviews, and review of facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, the facility failed to ensure pressure ulcer treatments were provided according to the wound physician's dressing treatment plans for two residents (R) (R1and R7) from a total sample of 21 residents.

Inspectors wroteBased on a staff interview and record reviews, the facility failed to ensure that annual performance reviews were completed, to enable in-service education based on the outcome of the reviews for 10 of 27 Certified Nurse Assistants (CNAs) reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the physician was notified timely of extensive bruising to one resident (R) (R8) from a total sample of 21 residents.

Inspectors wroteBased on staff interviews, record reviews, and review of the facility's policies titled Charting and Documentation and Telephone Orders, the facility failed to maintain a clinical record in accordance with accepted professional standards and practice by ensuring that licensed nursing staff did not falsify the physician's signature when completing telephone order forms for one Resident (R) (R14), from a total sample of 21 residents.

Inspectors wrote2. During an observation of wound care for R4 on 7/29/2024 at 4:20 pm, Registered Nurse (RN) AA provided wound care treatment to the resident's right ankle pressure ulcer and right lateral calf non-pressure ulcer without wearing a gown. There was no PPE available outside of the resident's room. During the interview on 7/30/2024 at 1:15 pm, the Infection Preventionist Nurse stated that R4 would most likely qualify for enhanced barrier precautions since she had wounds to her ankle. Based on observation, record review, and staff interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for two residents (R) (R4 and R7) who had pressure ulcers from a total sample of 21 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Of Life - Homelike Environment, the facility failed to provide a clean, comfortable homelike environment for the bathroom of residents residing on one hall (300 Hall) of three halls that include odors, torn floor coverings, stains, grime build up, and brown substances in some areas. The facility census was 64.

Inspectors wroteBased on staff interviews and record review of facility policy titled, Food Service Staffing, the facility failed to ensure that the staff designated as director of food and nutrition services was a certified dietary or food service manager or had a similar food service management certification or degree. The deficient practice had the potential to affect 50 of 52 residents who received an oral diet.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain a safe, clean, sanitary, and homelike environment as evidenced by stained and bowing ceiling tiles in resident rooms and bathrooms on two of three halls (rooms 220, 221, 222, 301, 302, 303), one bathroom light needing repair (room [ROOM NUMBER]), and one baseboard needing repair (bathroom [ROOM NUMBER]).

Inspectors wroteBased on record review, resident and staff interview, the facility failed to enter an order for in/out self-catheterization in the record for one resident ((R) R # 47) of one resident requiring self-catheterization.