The Pines Nursing And Rehabilitation Center

Based 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. The findings are: 1. On 03/30/25 at 10:34 AM, Dietary [NAME] (DC) #4 was wearing gloves on his hands when he deboned seven (7) servings of chicken thighs and emptied them into a blender to ground. He brushed spilled pieces of meat crumbs from the counter into his gloved hands, contaminating the gloves. He then removed the gloves from his hands and placed new gloves contaminating them by not washing his hands. He used his contaminated gloved hands to push ground chicken into a pan to be served to the residents who received mechanical soft diets for lunch. 2. On 03/30/25 at 11:27 AM, one packet of turkey slices was on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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%. The findings include: 1. A review of the quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) 02/26/2025, revealed Resident #29 had a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact. a. A review of the Care Plan Report for Resident #29 (revision date 11/26/2024), revealed that Resident #29 had altered respiratory status/difficulty breathing related to (r/t) Congestive Heart Failure (CHF), Obstructive Sleep Apnea (OSA), and asthma. Administer medication/treatment as ordered and observe for effectiveness. b. A review of the Medication Administration Record (MAR) revealed that Resident #29 had an order for a [Name brand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. During the observation of noon meal preparation in the kitchen on 03/30/25 at 10:34 AM, Dietary [NAME] (DC) #4 deboned seven (7) pieces of chicken thighs into a blender, of which one chicken thigh weighed 1.7 ounces, ground, and placed into a pan to serve 14 residents who received mechanical soft diets. 2. During an observation of noon meal service on 03/30/25 at 12:11 AM, DC # 4 used a #8 scoop (4 oz) to serve ground fried chicken. He gave half a portion (2 oz or 1/2 cup) per serving. DC #6, who observed DC #4, stated she should have given full serving to the residents, instead of half servings. 3. During an interview on 03/30/25 at 12:41 PM, DC #4, who prepared lunch meals, was asked how many residents were on mechanical soft diets. He stated about seven (7) residents. He was also asked how many servings of fried chicken he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/25/2025, indicated Resident #64 had a Brief Interview for Mental Status (BIMS) score of 14 (indicating the resident was cognitively intact), and had diagnoses including anemia, heart failure, pneumonia, and Multidrug-Resistant Organism (MDRO). The resident was receiving intravenous (IV) antibiotics. 2. On 04/01/2025 at 3:19 PM, Licensed Practical Nurse (LPN) #2 was observed administering an IV antibiotic solution to Resident #64. The resident's room was observed to have signage on the door indicating the resident needed Enhanced Barrier Precautions (EBP) for high-contact care. The EBP sign indicated staff should wear Personal Protective Equipment (PPE), that included both a gown and gloves. a. LPN #2 took medication and pump to the resident's room, performed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: A review of the facility's undated policy titled Notification of Change, indicated The nursing facility will immediately inform the Resident/Elder and consult with the Resident/Elder's physician, when a significant change occurs. The nursing facility will also notify the Resident/Elder's legal representative or a designated contact person when a significant change occurs. A review of the admission Record, indicated Resident #3 had diagnoses that included type 2 diabetes, pressure ulcer to the left buttock, heart disease, muscle weakness, difficulty walking, pain, cognitive communication deficit, and a history of falling. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/22/2024, revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: 1. A review of the admission record, indicated the facility admitted Resident #2 with diagnoses that included liver failure, metabolic disorder, major depression, schizophrenia, and sepsis left buttock stage 4 pressure ulcer. The signification change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #2 had a Staff Assessment of Mental Status (SAMS) score of 2 which indicated the resident was moderately impaired for daily decision making Resident #2 had a stage 4 pressure ulcer. A review of Resident #2's care plan, revealed the resident had a left lluteal stage 4 pressure ulcer. Interventions included to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: 76). The findings are: 1. On 02/20/24 at 10:06 AM, Dietary Employee (DE) #1 took the coffee dispenser to the dining room and walked back into kitchen. Without washing her hands, she picked up glasses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: 1. Resident #39 had diagnoses of Metabolic encephalopathy, Diabetes mellitus, and Anemia. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/14/24 documented that the resident scored 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). a. A physician's order dated 12/23/2023 documented, .send resident out to [named organization] emergency room for possible GI bleed . b. Resident #39 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. The hospital progress notes documented, .Discharge Summary .12/27/23: Pt (patient) admitted [DATE] for 1. GI (Gastrointestinal) Bleed 2. UTI (Urinary Tract Infection)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. On 02/20/24, the menu for the lunch meal documented residents who received regular were to receive 3oz (ounces) of baked ham; and residents who received pureed diets were to receive a # (number) 8 scoop of pureed ham (4oz) and a #8 scoop (1/2 cup) of pureed cornbread. 2. On 02/20/24 at 01:07 PM, the residents' regular diets were served less than 3 ounces of baked ham, instead of 3 ounces as per the menu. 3. On 02/20/24 at 01:10 PM, the resident on a pureed diet was served pureed dressing, pureed ham, pureed turnip greens and pureed plain cake. There was no pureed cornbread served to the resident on a pureed diet. 4. On 02/20/24 at 01:18 PM, the surveyor asked Dietary Employee (DE) #3 the reason the resident on a puree diet was not served. DE #3 stated, The cornbread or bread were not pureed. The resident received stuffing. Is stuffing not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1.Resident #80 had diagnoses of Right fractured shaft of humerus, Anxiety, Depression, Gastroesophageal reflux disease (GERD), Hypertension (HTN), and Arthritis. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/11/23 documented that the resident scored 15 (13-15 indicates cognitively intact) and that the resident's overall goal was to discharge to the community. a. A physician's order dated 12/23/23 documented, .May discharge resident to home with all medications and personal belongings . b. A nurses note dated 12/23/23 at 10:52 documented, .resident signed and acknowledged all discharge paperwork. Signed out narcotics to resident. resident was then escorted out of facility to vehicle by this nurse. all personal belongings and medications sent home with resident . c. The MDS with an ARD of 12/23/23 noted, Discharge -return not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. Resident #32 had diagnoses of Heart Failure, Cerebral Infarction, Cerebral Palsy, Abnormal Coagulation Profile, and Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 documented that the resident scored 13 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS) and required extensive assistance with toileting, totally dependent for transferring, and required set up and supervision with eating. a. The Physicians Order dated 10/21/22 documented, .Resident wishes to not be given any medications prior to noon . b. The Medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings are: 1. Resident # 32 had diagnoses of Heart Failure, Cerebral Infarction, Cerebral Palsy, Abnormal Coagulation Profile and Hypertension. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/22 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with toileting, totally dependent for transferring, and required set up and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings are: a. On 12/07/22 at 8:10 AM, on the entrance to the 100 Hall there was an unlocked medication cart. There were no staff visible on 100 Hall or in the nurse's station. The Surveyor waited until Licensed Practical Nurse (LPN) #1 returned to cart. When LPN #1 returned to the medication cart the Surveyor asked, Should the medication cart be unlocked and unattended? LPN #1 stated, No, it should not, but I heard a resident yelling down the hall, and I had to go check on them. The Surveyor asked, What room did you have to go to? LPN #1 stated, I rushed to room [ROOM NUMBER]. The Surveyor asked, Why should the medication cart not be unlocked and unattended? LPN #1 stated, The residents may get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: During an interview on 12/08/2022 at 2:06 PM, the Administrator stated the facility did not have a policy regarding care plan meetings. A review of a resident demographic record revealed Resident #74 was his/her own responsible party. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident had active diagnoses of coronary artery disease, heart failure, non-Alzheimer's dementia, anxiety, and depression. Per the MDS, the resident had no hearing, speech, or vision impairment. Review of Resident #74's care plan revealed the last care plan review was completed on 10/16/2022. The name and signature…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.