White Pine Care Center

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure comprehensive care plans were created for 1) contractures and its management for 2 of 12 sampled residents (Resident 9 and 10) and 2) use of psychotropic medications with its corresponding indications and diagnoses for 5 of 12 sampled residents (Resident 9, 20, 36, 37 and 38). The deficient practice had potential for residents not to have care that is person centered pertaining to their diagnoses, medications, monitoring and care needs.

Inspectors wroteBased on interview, record review and document review the facility failed to ensure consent for psychotropic medications were obtained for psychotropic medications for 2 of 12 sampled Residents (Resident 37 and 38). The deficient practice had the potential for resident or resident representatives to be informed of the purpose and the possible side effects of medication affecting brain functions.

Inspectors wroteBased on interview, record review and document review the facility failed to ensure 1) monitoring of psychotropic medications were documented in the medical record for 2 of 12 sampled Residents (Resident 9 and 20), and 2) psychotropic side effect monitoring orders were obtained for 3 of 12 sampled Residents (Resident 36, 37, and 38). The deficient practice had a potential for residents not to be monitored for early signs of side effects caused by psychoactive medications.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure timely reporting to the State Agency of an incident of abuse for 1 of 12 sampled Resident (Resident 30). The deficient practice had potential for an untimely review by the SA of the investigative process completed by the facility to ensure corrective actions were taken.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure 1) a neurological check after a head injury was completed for 1 of 12 sampled Residents (Resident 14). The deficient practice had potential for a resident not to be monitored for latent effects of a head injury and 2) splinting orders were obtained for 1 of 12 sampled Resident (Resident 9). The deficient practice had potential for not receiving continuity of care with prevention of contractures.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident was assessed and interventions were implemented for upper extremity contractures for 1 of 12 sampled Residents (Resident 10). The deficient had potential for a resident not to maintain mobility and prevent the progression of contractures.

Inspectors wroteBased on observation, interviews, record review and document review, the facility failed to ensure Oxygen (O2) saturations (a measure of how much oxygen a person's blood is carrying, expressed as a percentage) were obtained as ordered for the titration of O2 for 2 of 12 sampled residents (Resident 4 and 36). The deficient practice had potential for a resident to receive more O2 than what the body requires. Resident 4 (R4) R4 was admitted on [DATE], with diagnoses including chronic kidney disease and hypertension. On 05/04/2025 at 3:45 PM, R4 was observed sitting by the bedside with an oxygen cannula. The resident's concentrator (a medical device that separates oxygen from air, providing a higher concentration of oxygen to individuals who need supplemental oxygen therapy) was set to deliver 4 liters of Oxygen. R4 shrugged shoulders when asked who adjusts the level of the Oxygen machine. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure 12-hour annual in-service training, as required for five of five Certified Nurse Aides (CNAs) (CNA4, CNA6, CNA5, CNA3, and CNA2) reviewed for training requirements. This failure placed the residents at risk of lacking the required knowledge and competency to perform their duties.

Inspectors wroteBased on interview, record review, and review of the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 17 sampled residents (Resident (R) 5). The facility failed to accurately assess a fall with injury and this failure placed R5 at risk of having unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, interviews, record review, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to ensure that 1 of 17 sampled residents (Resident (R) 10) had a comprehensive care plan developed that addressed communication needs and failed to ensure 2 of 17 sampled residents (R19 and R28) had a comprehensive care plan developed that addressed nutrition. The deficient practices placed the residents at risk for not receiving appropriate patient centered care.

Inspectors wroteBased on observations, interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 13) reviewed for range of motion (ROM) and nutrition, had the care plans revised, and one resident (R5) reviewed for falls, had the care plan revised out of 17 sampled residents. The deficient practices placed the residents at risk for not receiving the care based upon their needs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assist with a communication deficit for one of one resident (Resident (R) 10), reviewed for communication out of 17 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being for 1 of 17 sampled residents (Resident (R) 13). This failure had the potential to negatively impact R13's quality of life.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide treatment to maintain or prevent further decrease in range of motion for 1 of 2 residents (Resident (R) 10) reviewed for range of motion out of 17 sampled residents. The deficient practice placed the resident at risk for developing decreased motion or contractures.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an investigation was performed and a root cause analysis was established for 1 of 1 residents (Resident (R) 5) reviewed for falls out of 17 sampled residents. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to provide interventions and meal assistance to address significant weight loss for one resident (Resident (R) 13) and ensure consistent weighing methods for one resident (R16) of the eight residents reviewed for nutritional status out of 17 sampled residents. This deficient practice placed the residents at risk for new or continued weight loss potentially impacting the resident's quality of life.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide appropriate person-centered and individualized treatment and services for one of two residents (Resident (R) 19) reviewed for behavioral healthcare needs of 17 sampled residents. This failure placed the resident at risk for increased distress and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed consultant pharmacist performed a monthly medication regimen review for December 2023, for two of five residents (Residents (R) 16 and R18) reviewed for unnecessary medications of 17 sampled residents. This failure placed the residents at risk of the physician and nursing staff not being aware of irregularities.

Inspectors wroteBased on interview, record review and review of the facility policy, the facility failed to ensure that indications and signs and symptoms for use of antibiotic medications were documented for 1 of 17 sampled residents (Resident (R) 2) resulting in the potential for adverse side effects from unnecessary medications.

Inspectors wroteResident 2 (R2) R2's admission Record revealed R2 was admitted to the facility on [DATE] with diagnoses which included neuromuscular dysfunction of the bladder, chronic respiratory failure, and hypertension. R2's quarterly MDS revealed R2 had a BIMS score of 15 out of 15 which indicated R2 was cognitively intact. A Progress Note dated 02/28/24, revealed R2 went to the Emergency Department (ED) on 02/28/24 for acute kidney failure, based on elevated blood work. Upon return to the facility R2 had an indwelling urinary catheter and had been diagnosed with a urinary tract infection (UTI), and started on an antibiotic. R2's EMR revealed no order for the urinary catheter. On 04/16/24 at 3:00 PM, R2 stated had the catheter for a while, but was unable to state when it was put in. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure hand hygiene and glove changes were performed for one of one resident (Resident (R) 3) reviewed for pressure ulcers of 17 sampled residents. This failure placed the resident at risk of infection.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to timely assess and monitor 1) a resident for changes of condition following a fall and failed to revise a care plan to prevent further falls (Resident (R) 31) and 2) failed to monitor a resident during the use of anticoagulant medication (and R29) for 2 of 15 sampled residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide Registered Nurse (RN) coverage for 8 hours within a 24-hour period on 10/29/22, 11/05/22, and 11/12/22. The facility census was 30.

Inspectors wrote3. Review of R232's face sheet revealed an admission date of 03/03/23. Review of R232's Diagnosis list revealed diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). Review of R32's Care Plan revealed no care plan for the use of supplemental oxygen. R32's Physician's Orders revealed no orders for the supplemental oxygen to include the rate and how often oxygen was to be used by R232. Review of the baseline care plan dated 03/03/23 for R232 indicated b. Physician orders/medications: (include catheter or any DME equipment) see Medication Administration Record/ Treatment Administration Record (MAR/TAR). Review of the MAR/TAR revealed no orders for the rate of oxygen needed for R232. On 03/09/23 at 2:59 PM, the DON confirmed the baseline care plan was not completed by staff to include R232's oxygen. [...]

Inspectors wrote3. Review of R26's electronic medical records (EMR) revealed the resident was admitted with diagnoses that included congestive heart failure (CHF), chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia. Review of the MDS with an ARD of 02/10/23 revealed a BIMS score of 14 out of 15 indicating R26's cognition was intact. The MDS indicated the resident was receiving oxygen therapy. Review of the resident's Physician Orders revealed R26 was on continuous oxygen (O2) at two liters (l) per nasal cannula (NC). The resident was also to have oxygen saturation (SPO2) (measurement of how much oxygen level in the blood) every shift. A review of the Vitals summary record located in the Weights/Vitals tab revealed from August 2022 to March 2023 the facility failed to obtain the SPO2 readings according to the physician's orders, 39 times. [...]

Inspectors wroteBased on observations, interview, record review, and review of facility policy, the facility failed to ensure: 1. the correct standard and transmission-based precautions were implemented and followed to prevent spread of infections for one of one resident (Resident (R)232) on isolation precautions, and 2. staff perform proper hand hygiene during meal service for three residents (R11, R18, and R24). The facility failure to adhere to correct isolation procedure and perform proper hand hygiene has the potential to result in the spread of infectious diseases throughout the facility.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to develop an effective antibiotic stewardship program which includes the Infection Control Preventionist, Pharmacy Consultant, and Medical Director.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the Centers for Medicare and Medicaid Services (CMS) form 10055 to inform the responsible party for one of three residents (Resident(R) 31) reviewed for beneficiary notices out of a total sample of 15 residents that services were no longer covered by Medicare

Inspectors wroteBased on record review, interview and document review, the facility failed to ensure it thoroughly investigated an allegation of neglect and failed to ensure it reported its final findings to the state agency for 1 of 11 residents (Resident #6).

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment for dentition was accurately coded for one of 18 sampled residents (Resident (R) 4). The facility's failure to accurately assess relevant care areas about the resident's status, needs, strengths, and areas of decline had the potential to not plan for and provide necessary care.

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed to develop a comprehensive care plan for use of anticoagulant and antidepressant medications for one of six sampled residents (Resident (R) 17) reviewed for unnecessary medication and failed to implement interventions for two of five sampled residents (R4 and R29) reviewed for nutrition in a total sample of 18 residents. The facility's failure to develop comprehensive care plan to address the resident's medications and failure to implement interventions for nutrition had the potential to result in necessary care not being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan to include physician orders to receive oxygenation saturation (SPO2) (measurement of how much oxygen is in the blood) readings every shift for one resident (Resident (R) 26) out of a sample of 15 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written discharge summary form was completed for one of two residents (Resident (R) 30) reviewed for discharge planning out of a total sample of 15 residents.

Inspectors wroteBased on record review, interview and document review, the facility failed to ensure 1 of 11 residents (Resident #6) received cardiopulmonary resuscitation (CPR) and activation of emergency medical services when needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure monitoring for an anticoagulant medication (medication that can cause increased risk for bleeding) was conducted for one of six sampled residents (Resident (R) 17) reviewed for unnecessary medication in a total sample of six residents. This failure had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure monitoring for an antidepressant medication was conducted for one (Resident (R) 17) and failed to have a stop date for a psychotropic PRN (as needed) medication for one resident (Resident (R) 31) out of six sampled residents reviewed for unnecessary medications out of a total sample of 15 residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to hold the administration of Clonidine (a medication used to lower blood pressure) prescribed by the physician to treat dementia related behaviors in light of low blood pressures and falls in one resident (Resident (R) 31) out of a total of 15 sampled residents. This failure increased the risk of R31 to have additional low blood pressure readings and increased falls.

Inspectors wroteBased on review of the daily nurse staffing forms and staff interviews, the facility failed to accurately report care hours provided by licensed and unlicensed personnel on daily posted nurse staffing forms dated 10/01/22 through 02/28/23. This failure increased the potential that residents and visitors would not know whether scheduled and/or actual staffing was sufficient.