The Pines Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items and leftover food items were promptly removed and/or discarded on or before the expiration or use by date, dietary staff washed their hands between dirty and clean tasks and before handling clean equipment, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting meal service for 1 of 1 meals observed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a medication error rate of less than 5% for two (Resident #5, #29) of five sampled residents observed during medication pass. Two (2) errors in medications were observed during thirty-eight (38) opportunities for errors in medication administration. This resulted in a medication error rate of 5.26%.

Inspectors wroteBased on observation, interview, and review of the menu, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of the 2 meals observed.

Inspectors wroteBased on observations, interviews, facility document review, and policy review, the facility failed to ensure Enhanced Barrier Precautions were implemented for 1 (Resident #64) of 2 Residents reviewed for Enhanced Barrier Precautions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to insulin administration for 1 (Resident #1) of 3 residents reviewed for newly admitted residents. Specifically, Resident #1 was admitted to a local hospital on 7/19/2024 due to a fall and left upper extremity pain. While at the hospital, the resident was diagnosed with left upper extremity thrombosis and had a necrotic ulcer on the left elbow, which was debrided at the hospital. On 07/31/2024, Resident #`1 was admitted to the nursing home facility with an order for continued anticoagulation (blood thinner) therapy. The resident's nursing home admission diagnosis was embolism or thrombosis of the arteries in the upper extremity. The physician's order for the blood thinner was not transcribed by the admitting nurse. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to notify the physician and/or the resident's representative of abnormal finger stick blood sugars, elevated white blood cell count, and the identification of a new pressure ulcer for 1 (Resident #3) of 4 residents reviewed for notification of change.

Inspectors wroteBased on observations, interviews, record review, facility document review, it was determined that the facility failed to ensure physicians orders were followed for wound care treatment for 2 (Resident #2 and Resident #4) of 3 residents reviewed for skin concerns and/or pressure ulcers. Specifically, the facility failed to ensure wound care was provided to residents when the designated wound care nurse was out sick.

Inspectors wroteBased on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure the ice machine was maintained in clean and sanitary condition to prevent contamination of airborne particles, failed to ensure food items stored in the refrigerator or freezer were sealed, labeled and dated, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, failed to ensure expired food items were promptly remove/discarded by the expiration or use by dates, and failed to ensure kitchen floors and kitchen walls were free of stains and chips. These failed practices had the potential to affect 75 residents who received meals from the kitchen (total census: [...]

Inspectors wroteBased on record review and interview, the facility failed to send the State Long Term Care Ombudsman a copy of the notice of transfer/discharge to the hospital to ensure protection of Resident Rights for 3 (Resident #12, #24, and #39) sampled residents who were discharged /transferred to the hospital.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set [MDS] accurately reflected the residents discharge status for 1(Resident #80) sampled resident who discharged home.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards over which the facility had control and provided supervision to each resident to prevent avoidable accidents for 1 (Resident #32) of 1 sampled resident. This failed practice had the potential to affect 18 residents residing on the 100 Hall who were self-mobile according to a list provided by the Administrator on 12/8/22 at 10:58 am.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure physician orders were followed to prevent a significant medication error for 1 (Resident #32) of 1 sampled resident who had physician orders for Cardizem LA twice a day and 1 (Resident #32) of 4 (Residents #28, #32, #74 and #78) sampled residents who had physician orders for Eliquis twice a day. This failed practice had the potential to effect 1 resident who had physician orders for Cardizem and 10 residents who had physician orders for Eliquis and resided in the facility according to a list provided by the Administrator on 12/08/22 at 1:45 pm.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored in a locked medication cart. This failed practice had the potential to affect 18 self-mobile residents who resided in the facility on the 100 Hall as documented on a list provided by the Administrator on 12/08/22 at 10:58 AM.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident was provided with the opportunity to participate in care planning meetings for 1 (Resident #74) of 24 sampled residents reviewed for care plan participation.