Pine Haven Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview conducted during the recertification and abbreviated survey (Case #s NY00309923 and NY00359733), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, between 3/23/2025 and 3/31/2025, the minimum hours of nursing care per resident day was less than the established minimum set by the Centers for Medicaid/Medicare Services. This is evidenced by: The Facility assessment dated [DATE], documented under Staffing plan, that the facility worked diligently to maintain staffing levels for all departments that met Center for Medicare and Medicaid Services Guidelines for providing optimal resident centered care. Facility Nursing Levels based on an Average Daily Census of 110 (in past 30 days) equaled 3.07 Hours Per Patient Day. Licensed Nursing equaled 1.43 Hours Per Patient Day. Certified Nurse Aides…

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 conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, (a) a container of tomato juice was found unlabeled in the refrigerator; and (b) a container of opened, unlabeled cranberry juice was found in the dry storage area. This is evidenced by: During the initial tour of the kitchen between 11:00 AM and 12:00 PM on 3/24/2025, the following was observed: (a) A pitcher with red liquid, unlabeled in the dessert refrigerator. At the time of observation, Kitchen Director #1 identified the red liquid to be tomato juice, stated there should have been a label on it stating it was opened today. Kitchen Director #1 then removed the pitcher and stated that they would refresh the supplies correctly. (b) An opened, unlabeled bottle of Ocean Spray Cranberry Juice in the dry storage area. At the time of observation, Regional Food Director #1 stated that a new employee that started a week prior had walked out an hour before the survey team arrived at the…

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 record review and interviews during a recertification and abbreviated survey (Case #NY00309923), the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made for one (1) (Resident #115) of eight (8) residents reviewed for abuse. Specifically, an allegation of verbal abuse reported by a resident to a Certified Nurse Aide on 2/05/2023 was not reported to Administration until 2/06/2023, and not reported to The New York State Department of Health until 2/08/2023. This is evidenced by: Facility policy titled, Abuse Policy-Prevention and Management, reviewed August 2024, documented the Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. Under the heading Identification the policy documents instruct staff, resident/patient, family, visitor, to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse. Under the heading Reporting the policy documents staff would…

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 conducted during a recertification and abbreviated survey (Case #NY00356721), the facility did not ensure the environment remained as free of accident hazards as possible for one (1) (Resident #41) of seven (7) residents reviewed for accident hazards. Specifically, for Resident #41 the temperature of the resident's microwave reheated beverage was not checked prior to serving, resulting in a first degree burn to the resident's chest. This is evidenced by: The facility Policy and Procedure titled Food - Microwave Reheating, last revised 7/26/2024, documented the staff were to use the thermometer to ensure a maximum temperature of the reheated food or beverage was not greater than 140 degrees Fahrenheit prior to serving. Resident #41 was admitted to the facility with diagnoses of anxiety, chronic pain and peripheral venous insufficiency (veins have trouble sending blood from limbs back to the heart). The Minimum Data Set, dated [DATE] documented the resident could understand, be…

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 staff interview during the recertification survey on 03/23/2022 through 03/30/2022 the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations. Specifically, food brought to residents was not labeled and discarded per the facility policy. This is evidenced as follows: The policy titled Food from Home - Safety dated 09/2021, documented food brought in from the outside will be labeled by staff with the resident name and dated with the current date the item(s) was brought to the facility and will be discarded after 72 hours. The policy documented unlabeled/undated food found will be discarded immediately. During observations on 3/24/22 at 9:45 AM, store-bought cold cuts and a frozen entree were found in the North Unit Nourishment Station refrigerator. Both the bologna and baked ham cold cuts were not labeled with the resident room number, or the date received. The bologna had sell-by date printed on the package of 2/17/22, and the bologna was moldy. The surveyor witnessed the…

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 record review during a recertification survey on 03/23/2022 through 03/30/2022 the facility did not ensure each resident received adequate supervision to prevent accidents for 2 (Resident #s 22 and 59) of 8 residents reviewed for accidents. Specifically, for Resident #22 and #59, the facility did not ensure the residents' nursing assessments documented the residents were able to self-administer medications, had a care plan or a physician order to self-administer medications that were left at bedside by nursing staff. This was evidenced by: The Policy and Procedure (P&P) titled Medication Administration dated 1/2022 documented residents may self-administer their own medications if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Resident #22: Resident #22 was admitted to the facility with diagnoses of gastro-esophageal reflux disease, atherosclerotic heart disease, and benign prostatic hyperplasia. The Minimum Data Set (MDS - an…

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 record review during a recertification survey on 03/23/2022 through 03/30/2022, the facility did not ensure it provided separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility used single unit package drug distribution systems in which the quantity stored was minimal and a missing dose could be readily detected for 1 (South Unit) of 2 units reviewed. Specifically, the facility did not ensure the #2 narcotic cabinet for the South Unit had two functioning locked doors. This was evidenced by: During an observation on 03/30/2022 at 9:38 AM, the #2 double door narcotic cabinet on South Unit, did not have a functioning lock on the inner door. The inner door had a strip of greying white tape affixed to the bottom of the door with a small portion extended from the bottom of the door which was used to pull the door open. Licensed Practical Nurse (LPN) #5 was observed unlocking the…

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, record review and interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs for 8 (Resident #'s 3, 14, 17, 29, 31, 46, 48, and 54) of 23 residents reviewed for comprehensive care plans. Specifically, for Resident #3, the facility did not ensure that the CCP for Feeding Tube did not include an incorrect physician order for the tube feeding; for Resident #14, the facility did not ensure the comprehensive care plans for depression and anxiety included person centered non-pharmacological interventions; for Resident #17, the comprehensive care plan for Activities of Daily Living that documented the resident ambulated (walked) with extensive assist of one was implemented; for Resident #31, the CCP for Pain did not include the etiology of the pain; for Resident #46, the CCP for mood…

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 staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving area floors and equipment are to be kept clean, and kitchen equipment is to be kept in good repair. Specifically, equipment in the main kitchen and unit nourishment Stations were not clean and/or not in good repair; and the facility did not ensure proper food handling practices for residents in the Haven dining room. This is evidenced as follows. Finding #1: The main kitchen and the nourishment stations were inspected on 10/16/2019 at 08:51 AM. Drawers, mixer, slicer, microwave ovens, and stove were soiled with food particles. The floors next to walls and under equipment were soiled. The food preparation sink in the main kitchen had an open hole where the overflow drain and pipe should be connected, and open holes were found in the upper lip next to the faucets in the Nourishment Stations on the west and north units. The Food Service Director stated in…

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, record reviews, and interviews during the recertification survey, the facility did not ensure residents were treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life in the Haven dining room for 4 (Resident #'s 24, 29, 30, and 46) of 5 residents reviewed for dignity, and did not ensure residents were transported in a dignified manner for 1 (Resident #81) of 5 residents reviewed for dignity. Specifically, the facility did not ensure residents' were provided dignity during dining, when staff were observed standing and feeding multiple residents at the same time, that food under a residents mouth was not caught by bare hands rather than using a clothes protector, that a resident was not transported in a wheelchair in a rear-facing position down 2 hallways, and did not attend to a resident who was yelling out and crying in a timely manner. This is evidenced by: Finding #1: The facility did not ensure residents' were provided dignity during dining, when staff were…

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, interview, and record review during the recertification survey, the facility did not ensure each resident received treatment and care in accordance with standards of practice for 1 (Resident #81) of 4 residents reviewed for positioning. Specifically, the facility did not ensure a resident received the needed care or services for positioning resulting in one or more residents' failure to attain their highest practicable physical well-being, and did not ensure the resident's response to a positioning intervention was monitored and evaluated in a timely manner. This is evidenced by: Resident #81: The resident was admitted to the facility on [DATE], with diagnoses of anxiety disorder, dementia, and bipolar disorder. The Minimum Data Set (MDS - an assessment tool) dated 9/25/19, documented the resident had severely impaired cognitive skills for daily decision making, could sometimes understand others and could sometimes make self understood. A Policy and Procedure (P&P) titled Positioning of the…

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 interviews during a recertification survey the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR's), and behavioral interventions, in an effort to discontinue these drugs and did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 3 (Resident #'s 14, 46, and #48) of 5 residents reviewed for psychotropic medications. Specifically, for Resident #14, the facility did not ensure the attending physician or prescribing practitioner was presented with the need to attempt a GDR in the absence of identified and documented clinical contraindications for a resident on Remeron (a psychotropic medication); for Resident #46, the facility did not ensure that the…

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 observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received, and the facility provided food that accommodated resident allergies, intolerances, and preferences, for one (Resident #63) of one resident reviewed for dietary preferences. Specifically, for Resident #63, the facility did not ensure the resident was provided with his preference of Activia yogurt when available. This is evidenced by: Resident #63: The resident was admitted to the facility on [DATE], with diagnoses of cerebral infarction, hypertension, and depressive episodes. The Minimum Data Set (MDS - an assessment tool) dated 9/9/19, documented the resident had severely impaired cognition, could understand others and could make self understood. The Policy and Procedure titled Flexible Dining Program Policy dated 12/1/2017, documented tray cards are used to communicate care plan interventions to the resident and staff for use in making mealtime selections. Resident's…

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.