Pinewood Healthcare Center

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy titled Date Marking for Food Safety, the facility failed to ensure that food items were properly dated, labeled, and discarded in the refrigerator, freezers, and dry storage. These deficient practices had the potential to place the 47 residents who received meals from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 29 Residents (R) (R31) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, the facility failed to report to the State Survey Agency (SSA) within the required two-hour time frame a fall with major injury for one of two Residents (R) (R2) reviewed for falls.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure that aerosol containers and cleaning chemicals were not stored in three of 47 resident rooms (room [ROOM NUMBER], 40, and 42). This deficient practice increased the risk for accidents.

Inspectors wroteBased on observations, interviews, record reviews, and review of Bylaws of the Board of Trustees, the facility's Governing Body failed to ensure that supply vendors were paid in a timely manner, so that there was not a disruption in supplies for resident care needs. This failure resulted in the deinstallation of linens by the facility's linen supply company on 6/11/2025.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Manual Warewashing-3 Compartment Sink and Dishwasher Temperature, the facility failed to ensure all dishes, pots, pans and cooking utensils were properly sanitized to decrease the risk of spread of infection and cross contamination. This was evidenced by the facility staff not having the proper method to check the sanitizer solution concentration levels for the dish machine and three compartment sink. The deficient practice had the potential to affect 53 out of 56 residents that received an oral diet from the kitchen.

Inspectors wroteBased on staff interviews and record review, the facility Administration failed to ensure oversight of the kitchen to ensure proper sanitation of pots, pans, dishes, utensils and countertop surfaces. This was evidenced by the Administration not being aware the dish machine and three-compartment sink did not have proper sanitation; and was not aware that the thermostat on the dish machine was inoperable. Also, the Dietary Manager did not have a Certified Dietary Manager (CDM) certification or equivalent. The deficient practice had the potential to affect 53 out of 56 residents that received an oral diet from the kitchen.

Inspectors wroteBased on observation, staff interviews, record review, and review of facility's policies titled Hand Hygiene, and Enhanced Barrier Precautions, the facility failed to perform hand hygiene between residents for six out of 21 residents observed during meal service, to prevent the spread of infection and communicable diseases. In addition, the facility failed to don gown prior to administering medications to one of three Residents (R) R53 with a gastrostomy (G-tube).

Inspectors wroteBased on observations, staff interviews, record review and review of facility's policy titled Abuse, Neglect and Exploitation, the facility failed to report an injury of unknown source for one out of one Resident (R) R5 reviewed for abuse.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review), the facility failed to refer one out of two sampled Residents (R) R1 with a serious mental disorder for a Level II PASARR.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to implement a comprehensive person-centered care plan for one out of 21 sampled Residents (R) R53. Specifically, R53's care plan was not followed by staff in regard to Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. The deficient practice had the potential to affect 69 residents with trust fund accounts managed by the facility.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to obtain a Physician's signature on the Physician Orders for Life Sustaining Treatment (POLST) for an Attempt Resuscitation Cardiopulmonary Resuscitation (CPR) consent for one Resident (R) (R#40) and failed to complete a subsequent review of the POLST for one Resident (R) (R#33). The sample size was 24 residents 1. Review of POLST: Guidance for completing the POLST form revealed: If the patient has decision making capacity, that patient chooses whether to complete and sign the POLST with his or her physician. Review of Minimum Data Set (MDS) dated [DATE] revealed R#40 had a Brief Interview of Mental Status (BIMS) score of 15. Review of medical record for R#40 revealed no documented Advance Directives and a POLST with a choice to attempt resuscitation (CPR) but there was no Physician's signature. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the responsible party of a change in condition for one resident ((R) R#73) of six residents sampled.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to accurately revise Advance Directive care plan and include measurable objectives and timeframes for one resident ((R#33) of 24 sampled residents.

Inspectors wroteBased on observation. record review, and resident and staff interviews, the facility failed to provide an individualized activities program to meet the needs for one resident ((R#66) of 69 residents.