The Pines Healthcare & Rehab Ctrs Machias Campus

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00359779, and #NY00363581) during an Extended Standard survey completed on 2/3/2025, the facility failed to protect residents from abuse by other residents for three (3) (Resident #17, #71, and #75) of 12 residents reviewed. Specifically, on 11/4/2024, Resident #68 struck Resident #71 in the face with their walker, resulting in a laceration across the bridge of Resident #71's nose, and skin tears to their right cheek and chin. Additionally, on 12/5/2024, 12/10/2024, and 12/11/2024, physical altercations occurred between Residents #17 and #75, who were roommates and remained roommates until after the third altercation on 12/11/2024. This resulted in actual harm to Resident #71.

Inspectors wroteBased on interview and record review conducted during an a Complaint investigation (#NY00330289, #NY00331807, #NY00341814, #NY00354482, #NY00357719, #NY00359779, #NY00363581, and #NY00363961) during the extended Standard survey completed on 2/3/25, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. In addition the facility did not ensure their abuse reporting policy and procedures were updated to include current regulations and guidance. Specifically, the facility did not ensure their policy for abuse reporting was current. This affected 10 (Residents #17, 30, 42, 47, 68, 71, 72, 75, 95, and #161) of 12 residents reviewed. [...]

Inspectors wroteBased on interviews and record review conducted during a Complaint investigations (#NY00330289, #NY00359779, #NY00363581, #NY00341814, #NY00354482, #NY00331807, #NY00357719, #NY00363961) completed during an extended Standard survey on 2/3/25, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to administrator of the facility and to other officials (including to the State Survey Agency) for 10 (#17, #30, #42, #47, #68, #71, #72, #75, #95 and #161) of 12 residents reviewed. [...]

Inspectors wroteBased on interview and record review conducted during an extended Standard survey completed on 2/3/2025, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00341814) during an extended Standard survey completed on 2/3/25, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (1) (Resident #161) of one (1) reviewed for dignity. Specifically, the certified nurse aide provided care despite the resident's refusal and resulted in Resident #161 feeling ashamed and humiliated. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review conducted during a Complaint investigation (#NY00341814, #NY00354482, #NY00363961) during an extended Standard survey completed on 2/3/25, the facility did not ensure that all residents care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for three (Residents # 30, 42, & 161) of three resident's reviewed. Specifically, care plan interventions were not followed by staff. Issues included: protective sleeves (#30), and shorts (#42) were not provided as planned, and a side rail was left in the up position when care was not being provided (#161) all breaks in implementation resulted in minor injuries.

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00323316) completed on 9/13/23, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for one (Resident #1) of three residents reviewed. Specifically, staff did not implement Resident #1's care plan intervention for the use of dycem (a nonslip, self-adhesive mat) in their recliner consistently across all shifts. The finding is: The policy and procedure (P&P) titled Assignments/Accountability revised 11/19, documented all staff will be held responsible for checking the residents Kardex (a guide for providing care)/care plan prior to providing care. 1. Resident #1 had diagnoses including cerebral infarction (stroke), cognitive impairment, and repeated falls. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on [DATE], the facility did not ensure the system developed for advanced directives was implemented in a manner that was consistent with resident's wishes for one (Resident #33) of three residents reviewed for advanced directives. Specifically, the facility did not ensure all resident advanced directives identifiers were consistent with the resident's wishes. The finding is: 1. Resident #33 was admitted to the facility on [DATE] with diagnoses that included delusional disorders, anxiety disorder and major depressive disorder. The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Complaint investigation (#NY00288007) during the Standard survey completed on 1/27/2023, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment are thoroughly investigated for one (Resident #26) of two resident reviewed. Specifically, the facility did not complete an investigation into an injury (left hand swelling with bruising middle finger) of unknown origin. The finding is: The facility policy and procedure titled, Abuse Prevention and Reporting dated 10/21 documented an abusive act is defined as any act of commission or omission that causes potential or actual physical or emotional harm or injury to a resident. The Director of Nursing or his/her designee will notify the attending physician immediately if the resident requires medical attention. [...]

Inspectors wroteBased on observation, interview, and record review during the Standard survey started on 1/23/23 and completed on 1/27/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility did not develop policy and procedures regarding medical marijuana use. This involved Resident #58. The finding is: 1. Resident # 58 was admitted to the facility with diagnoses which included dorsalgia (back pain), polyneuropathy (a disease process involving a number of nerves), and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 12/22/22 documented Resident #58 was cognitively intact, had frequent pain, received scheduled pain medications, prn (as needed) medications, and non-medication interventions. [...]

Inspectors wroteBased on interview and record review during the Standard survey completed on 1/15/20, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility did not provide documentation that verified one (Food Service Helper) of five employees that worked in the facility, during the last four months, and were subject to the New York State Nurse Aide Registry, had been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: A review of the facility's policy for Abuse Prevention, revised 9/2016, revealed: All applicants, regardless of department, will be screened through the on-line New York State Nurse Aid Registry for record of abuse prior to hire. [...]

Inspectors wroteBased on interview and record review completed during the Standard survey completed on 1/15/2020, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one for one (Resident #9) of three residents reviewed for pressure ulcers. Specifically, the lack of weekly pressure ulcer assessments to include measurements. In addition, the lack of care plan development for the pressure ulcer on the left foot 3rd toe. The finding is: The facility policy and procedure titled Pressure Ulcer/Wound management and Treatment revised 7/2018 documented a Registered Nurse (RN) will accurately assess and reassess all wounds/pressure ulcers on a weekly basis/at least every seven days. [...]