The Pines Post Acute and Memory Care

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. One of three medication carts was observed unlocked and unattended during medication administration. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. The Memory Lane medication cart was unlocked and unattended during medication administration on 7/17/25.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 44 residents residing in the facility. Staff did not test the parts per million (PPM) of the Quaternary sanitizing solution per the manufacturer's instructions. The reach-in cooler did not maintain a consistent and safe temperature for items that required storage at 41 degrees Fahrenheit (F) or below. The reach-in cooler contained unlabeled, undated, and/or expired items.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R21) of 16 sampled residents had a call light within reach and was provided hearing aids. On 7/16/25, R21 was in R21's room without access to a call light or a means to notify staff if assistance was needed. In addition, R21 did not have hearing aids in either ear on 7/15/25.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a written transfer and/or bed hold notice or Ombudsman notification was provided when 2 residents (R) (R45 and R47) of 2 sampled residents transferred to the hospital and/or discharged from the facility. R45 was transferred to the hospital on 4/14/25 and 5/13/25. Neither R45 or R45's Guardian were provided a written transfer notice. R45 was also transferred to the hospital on 4/29/25. Neither R45 or R45's Guardian were provided a written transfer or bed hold notice. In addition, the Ombudsman was not notified of the transfers or R45's discharge from the facility following the 5/13/25 hospital transfer. R47 was discharged to an assisted living facility on 5/12/25. The Ombudsman was not notified of the discharge.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 resident (R) (R10) of 4 sampled residents. R10 had a fall with injury on 6/6/25. Following the fall, the facility did not implement or add physical therapy recommendations to R10's plan of care to prevent future falls or injury.

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate weight monitoring was provided for 1 resident (R) (R14) of 3 sampled residents. The facility did not update the physician regarding R14's weight loss of 6.15% from 6/6/25 to 7/4/25. In addition, the facility did not use the same device to obtain R14's weight on each weigh date.

Inspectors wrote2. On 6/19/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had a diagnosis of Parkinson's disease. R2's MDS assessment, dated 5/2/25, had a BIMS score of 9 out of 15 which indicated R2 had moderate cognitive impairment. R2 had a POAHC. R2's care plan indicated the following: ~ Sensor alarm to bed and chair to alert staff of self-ambulating so staff can assure R2 is using R2's walker ~ Do not put feet up in recliner, unable to put down independently Surveyor reviewed a fall investigation that indicated R2 was found on the floor of R2's room on 4/27/25 at 6:15 PM. CNA staff had assisted R2 to bed less than five minutes prior. A Licensed Practical Nurse (LPN) entered R2's room to administer medication at 6:15 PM and observed R2 ambulating independently in the room and bleeding above the right eye. [...]

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 (Certified Nursing Assistant (CNA)-C) of 8 staff reviewed for caregiver background checks. The facility did not ensure a thorough caregiver background check was completed for CNA-C.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents was free from being physically restrained. R1 had Alzheimer's disease and had a history of tearing apart R1's incontinence brief. On the 4/1/25 PM shift at approximately 9:30 PM, Certified Nursing Assistant (CNA)-C tied the sleeves of R1's nightgown closed with R1's arms inside and tucked a blanket across R1's lap and under both sides of the mattress after R1 repeatedly tried to rip off R1's brief. R1 was restrained in bed until approximately 12:10 AM when staff on the next shift did a routine check on R1. R1 was restrained in such a way that R1 could not access R1's hands or call light and could not move freely in bed. [...]

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures to prevent abuse and complete a thorough and timely background check for 1 (Certified Nursing Assistant (CNA)-H) of 8 sampled staff. The facility did not ensure a background check was completed every four years for CNA-H, including a Background Information Disclosure (BID) form, Department of Justice (DOJ) report, and an Integrated Background Information System (IBIS) letter.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 of 2 refrigerators in the medication storage room that contained vaccines and insulin maintained a temperature between 36 and 46 degrees. In addition, the facility did not ensure medications for 11 residents (R) (R23, R41, R11, R9, R12, R13, R32, R39, R7, R35, and R30) of 49 residents in 3 out of 3 medications carts were labeled and/or dated appropriately. Refrigerator temperature log sheets indicated temperatures were more than 46 degrees for a refrigerator in the medication storage room. During observations on [DATE], the thermometer in the refrigerator indicated the temperature was 52 degrees and 54 degrees. The refrigerator contained vaccines and insulin which should be stored between 36 and 46 degrees Fahrenheit (F) to preserve their integrity. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect multiple residents residing in the facility. Food cooling logs indicated food was cooled incorrectly on 6 occasions from December 2023 to April 2024.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 resident (R) (R49) of 1 resident observed during catheter care received appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R49 received catheter care in a manner that decreased the risk for infection.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 2 residents (R) (R35 and R12) of 5 residents observed during medication pass. On 5/14/24 at 8:45 AM, Surveyor observed Licensed Practical Nurse (LPN)-H administer an Advair Diskus inhaler (corticosteroid inhaler used for emphysema) to R35. An order for the inhaler indicated R35 should rinse R35's mouth with water and spit the water in a cup. LPN-H did not offer R35 water after administration of the inhaler or encourage R35 to rinse and spit. In addition, LPN-H crushed R35's enteric-coated ferrous (iron) sulfate tablet. On 5/14/24 at 8:55 AM, Surveyor observed LPN-H administer a Breo Ellipta (a corticosteroid inhaler used for asthma) inhaler to R12. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 resident (R) (R16) of 1 resident during the provision of wound care. R16 was on Enhanced Barrier Precautions (EBP). During an observation of wound care on 5/13/24, Licensed Practical Nurse (LPN)-C did not don the appropriate personal protective equipment (PPE) and did not perform appropriate hand hygiene.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of sexual abuse was thoroughly investigated for 2 Residents (R) (R22 and R39) of 2 sampled residents. Staff witnessed R22 grab R39's breast. The facility did not complete a thorough investigation for the allegation of sexual abuse.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure supervision in accordance with the resident's plan of care was provided for 1 Resident (R) (R22) of 15 residents reviewed. R22's plan of care contained an intervention for a motion detector on R22's door to alert staff when R22 exited the room. R22's plan of care also contained an intervention for R22 to be within eye sight while out of R22's room. The interventions were not consistently implemented.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure pureed food in accordance with a diet trial was provided for 1 Resident (R22) of 15 residents reviewed. R22 did not receive a pureed diet as indicated for the lunch meal on 5/8/23.