Pine Village

The facility had a census of 66 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to store food by professional standards for food service safety in one kitchen. This deficient practice placed the residents who received their meals from the facility's kitchens at risk for foodborne illness. Findings included: - On 05/04/25 at 08:34 AM, the silver upright freezer, located by the entrance door, inside the kitchen, had the following: A cardboard box had the plastic torn open, exposing four corn dogs. A cardboard box had the plastic torn open, exposing 19 (4-ounce (oz) beef burger patties. A cardboard box had the plastic torn open, exposing 16 (2.6oz) chicken patties. The walk-in fridge had an unlabeled, undated plastic bag with shredded radishes and a plastic bag with unlabeled, undated shredded carrots. On 05/04/25 at 08:34 AM, Dietary Staff (DS) CC verified the above findings and stated staff should cover food when placed in the freezer. DS CC stated that the shredded radishes and shredded carrots should have been…

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.

The facility had a census of 66 residents. Based on observation, record review, and interview, the facility failed to submit complete and accurate staffing information through Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter (Q) 1 indicated no Registered nurse (RN) hours for four days in October 2024 and two days in November 2024. A review of the facility's staffing and RN hours of the days listed above revealed RN coverage. On 05/06/25 at 09:18 AM, Administrative Staff B stated that Q1 was the first time she'd submitted the information by herself. Administrative Staff B stated that there had been the appropriate number of staff, and it was possible that salaried staff did not pull over to be submitted. On 05/06/25 at 11:50 AM, Administrative Staff A stated that the facility always had RN coverage and more than enough staff, that she did 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.

The facility had a census of 65 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to use appropriate barriers while sorting soiled laundry. This placed the residents at risk of infectious diseases. Findings included: - On 05/06/25 at 07:47 AM, while on tour of the laundry department, Maintenance/Housekeeping Staff U stated the soiled laundry was sorted by laundry staff using only gloves; unless there was obvious visual soilage, and then a gown would be worn. Maintenance/Housekeeping Staff U stated she had not thought about transferring soiled/potentially infectious laundry to the clean laundry. On 05/06/25 at 11:30 AM, Administrative Nurse D verified that laundry staff should wear clothing barrier and gloves while sorting soiled laundry. The facility's Laundry policy, dated 05/10/20, documents the facility launders linens and clothing in accordance with current Centers for Disease Control and Prevention (CDC) guidelines to prevent transmission of pathogens. Aligning with principles of standard precautions, staff…

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 The facility had a census of 66 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 30. This placed the resident at risk for physical decline and other related complications. Findings included: - The Electronic Medical Record (EMR) for R30 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissue), and hypertension (high blood pressure). R30's Quarterly Minimum Data Set (MDS), dated [DATE], documented R30 had severely impaired cognition. The MDS documented R30 required partial staff assistance for oral hygiene, toileting hygiene, bathing, transfers, and did 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.

The facility had a census of 72 residents. The sample included 18 residents. Based on record review and interview, the facility failed to complete performance reviews of all nurse aides, provide regular in-service education based on the outcome of these reviews, and ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for inadequate care. Findings included: - The facility's employment records documented the nurse aides who were employed at the facility for at least one year, review of the facility's in-service records documented one of the five Certified Nurse Aide (CNA) M lacked the required 12 hours of in-service training in the past year. On 08/30/23 at 09:30AM, Administrative Staff A and Administrative Nurse D stated CNA M had not completed the 12 hours of required in-service training in the last year. They stated the human resource personnel was responsible to keep track of the required hours. They stated the facility had staff turn-over in that department and did not monitor the staff completion of…

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 The facility had a census of 72 residents. The sample included 18 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post discharge plan for Resident (R) 71. This placed the resident at risk for missed care opportunities. Findings included: - R71's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. R71's admission Minimum Data Set (MDS), dated [DATE], documented R71 required limited staff assistance with activities of daily living (ADLs) except supervision with eating. The MD'S documented the resident expected to remain in the facility. The Return to Community Care Area Assessment (CAA) did not trigger. R71's Addendum to Baseline Care Plan, dated 06/05/23, documented an interdisciplinary evaluation to determine the support she needed to be safe and functioning at her highest…

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 The facility had a census of 72 residents. The sample included 18 residents of which 10 were reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when the facility failed to assess Resident (R)16 for safe use of an electric recliner. This placed the R16 at risk for injury due to preventable accidents and hazards. Findings included: - R16's Electronic Medical Record (EMR) recorded cerebral vascular accident (CVA-stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain,) hemiplegia (paralysis one side of the body,) anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and essential tremors. R16's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS recorded R16 required extensive staff…

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 The facility had a census of 72 residents. The sample included 18 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure an appropriate indication for use, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R)19, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed the resident at risk for unnecessary psychotropic (alters mood or thought) medications and related side effects. Findings included: - R19's Electronic Medical Record (EMR) documented she had a diagnoses of dementia, paranoid personality disorder, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty 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.

The facility had a census of 63 residents. The sample included 16 residents, with three reviewed for Beneficiary Notices. Based on record review and interview, the facility failed to provide one of the sampled residents, Resident (R) 115 (or their representative) the completed Notice of Medicare Non-Coverage (NOMNC) Form 10123 Centers for Medicare and Medicaid Services (CMS), and the completed Skilled Nursing Facility Advanced Beneficiary Notice of Non Coverage (SNF ABN) Form 10055 . Findings included: - The Medicare Form 10123 informed the beneficiary that Medicare may not pay for future skilled therapy. The form included detailed explanation of non-coverage and explained the appeal process The Medicare Form 10055 informed the beneficiary that Medicare may not pay for skilled therapy services and provided a cost estimate for continued services. It explained: (1) if Medicare does not pay, the resident would be responsible for payment, but can make an appeal to Medicare, (2) receive therapy listed, but do not bill Medicare, would be responsible for payment for services, or (3) does…

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 The facility had a census of 63 residents. The sample included 16 residents, with one reviewed for Pre-admission Screening and Annual Resident Review (PASARR). Based on observation, interviews, and record review the facililty failed to ensure a referral was made promptly by the nursing home to the state PASARR program for a Level 2 Resident Review for Resident (R) 63 who had a documented a mental illness (MI) or intellectual disability (ID). Findings include: - R63's Physician Order Sheet (POS), dated 04/30/21, recorded the diagnoses of Major Depressive Disorder (MDD) (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue) , cerebrovascular accident (CVA)(sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and wandering. R63's Quarterly Minimum…

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 The facility had a census of 63 residents. The sample included 16 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to follow toileting and fall interventions as directed in the resident's plan of care care for one sampled resident, Resident (R) 29, who had several falls. Findings included: - R29's admission Minimum Data Set (MDS), dated [DATE], documented the resident had intact cognition and required extensive assistance of one staff for bed mobility, transfers, toileting and limited assistance of one staff for ambulation in room. The MDS further documented the resident, occasionally incontinent of bladder, unsteady gait, had no upper or lower functional impairment, had one non- injury fall since admission, and did not use any alarms. The Quarterly MDS, dated 12/11/21, documented the resident had severely impaired cognition and required extensive assistance of one staff for bed mobility, transfers, toileting, and ambulation in room 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 The facility had a census of 63 residents. The sample included 16 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to accurately assess Resident (R) 5's side rails for safe use, placing R5 at risk for accident and injury. Findings included: - R5's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating moderately impaired cognition. The MDS documented the resident required extensive assistance of onestaff with bed mobility, transfer and locomotion on and off the unit. The MDS lacked documentation the resident had bedrails. The Activities of Daily Living (ADL) Care Plan, dated 12/13/21, indicated one staff assisted the resident with bed mobility. R5 utilized a quarter side rail (a structural support attached to the frame of the bed and intended to prevent a patient from falling and assist with transfers) to assist with repositioning and bed mobility. The Side…

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 The facility had a census of 63 residents. The sample included 16 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure appropriate diagnoses for the use of antipsychotic medications (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental illness conditions) for three sampled residents, Residents (R) 9, R29 and R14. This placed the residents at increased risk for inappropriate treatment and risk for adverse outcomes associated with antipsychotic medications Findings included: - R9's Physician Order Sheet (POS), dated 11/02/21, documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had severely…

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.