Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine View Nursing And Rehab Center during CMS and state inspections, most recent first.
Improper Puree Food Preparation: The facility failed to properly prepare pureed meals for eight residents on a pureed diet. One DA loaded food into a processor without measuring, did not use liquids or a recipe, and did not check the consistency before serving. Another DA prepared sweet potatoes without following the recipe or proper measurements, used broth instead of the documented ingredients, and stated she had not been formally trained. The DM confirmed staff were not using the puree recipe book and were being verbally instructed on ingredients.
Food storage and sanitation practices were not maintained in the kitchen. Surveyors observed ice buildup and icicles in the freezer, frozen foods stored without date labels, and an opened loaf of bread, molded cheese, an opened box of pancakes, and a staff member's personal medications in the refrigerator. Staff also used bleach at the 3-comp sink, prewashed dishes before the dishwasher, hand-dried items with a dish towel, and confirmed the dishwasher temperature gauge and chemical strips were not functioning properly.
The facility failed to maintain an effective QAPI program and could not produce documentation for review, including meeting attendance records and the QAPI policy. The Administrator stated the facility does not maintain QAPI documentation, the QAPI program is not effective, and there is no tracking or trending of data for trends; most issues are addressed during the morning clinical meeting. This deficient practice affected 109 residents.
Medication administration errors exceeded the allowed rate after an LPN gave multiple ordered G-tube medications by mouth to a resident and administered Seroquel at half the ordered dose. The resident’s orders and MAR matched, but the nurse did not follow the prescribed route or dosage, and facility leadership stated nurses were expected to follow physician orders and the rights of medication administration.
A resident with a G-tube, dysphagia, and multiple chronic conditions was ordered several medications to be administered via the G-tube. During observation, an LPN gave all of the medications by mouth instead of by the ordered route and confirmed the orders called for G-tube administration; an APRN later verified that the resident should have received the medications via the G-tube.
The facility failed to ensure proper infection control during meal service, as CNAs did not sanitize their hands between resident contacts on two halls. Additionally, the facility lacked an effective water management program to prevent Legionella growth, as the previous Maintenance Director took all related documentation upon leaving. The facility was in the process of developing a new program.
The facility failed to maintain a safe and sanitary environment, with issues such as patched walls, stained ceiling tiles, and foul odors noted in multiple areas. The D Hall had a persistent urine odor, linked to bins containing soiled linens and incontinence pads. Staff confirmed these conditions, and the Administrator acknowledged the need for an odor-free environment.
A resident was found with unauthorized vitamins at their bedside, despite facility policy requiring physician authorization for bedside medication storage. Staff interviews confirmed that medications are not allowed at the bedside without specific authorization, and the vitamins were subsequently removed by an LPN.
A facility failed to provide written bed hold notices for a resident who was hospitalized twice, as required by their policy. Despite the policy being part of the admission packet, the Business Office Manager confirmed that no bed hold notice was issued during the resident's hospital transfers, leading to a deficiency.
A facility failed to accurately code the MDS assessment for a resident with mental health diagnoses, including schizophrenia and bipolar disorder. The resident's MDS incorrectly stated that a Level II PASRR evaluation had not been conducted, despite it being completed. The MDS Coordinator confirmed the error, and RN GG, responsible for signing off on the MDS, did not check for accuracy. The Administrator acknowledged the lack of a specific MDS policy, relying instead on RAI guidelines.
Two residents in the facility did not receive adequate ADL care. One resident with severe cognitive impairment had long, dirty fingernails, while another resident, dependent on assistance for ADLs, reported not receiving help with brushing teeth for over two weeks. CNAs confirmed the lack of care, and the DON stated that nail and oral care should be part of daily ADL care.
The facility failed to document controlled medication shift counts with nurse signatures on the D Hall Medication Cart, missing 28 signatures out of 112 opportunities. This deficiency was identified through observations and staff interviews, revealing a lack of adherence to the facility's policy on controlled substances. The Nursing Supervisor and DON emphasized the importance of signing the controlled substance sheet at each shift change to ensure medication availability.
Expired medications were found in a medication storage room, including 14 blister packs and bottles of vitamin D, despite facility policy requiring their removal. An LPN and Nursing Supervisor confirmed the oversight, and the DON stated that expired medications should be removed to prevent resident exposure.
Improper Puree Food Preparation
Penalty
Summary
The facility failed to properly prepare pureed food and ensure nutritive value for eight of eight residents receiving a pureed diet. The facility’s Nutrition Policy stated that pureed food should be a smooth, pudding-like texture and that pureed recipes are needed for each item requiring fluid and mechanical manipulation, using only nutritive fluids such as broth, gravy, juice, and milk. During observation of the puree process, Dietary Aide II loaded food into a processor without measuring, did not use liquids to dilute or liquify the food, did not follow a recipe, and did not assess the consistency before transferring it to a serving tray. In interview, the aide stated she was not aware she had to use a recipe and had not been trained on the proper technique for puree preparation. A second observation showed another Dietary Aide preparing sweet potatoes by placing seven scoops into a food processor, adding three scoops of broth, blending the mixture, tilting it back and forth, and pouring it into a serving tray. She stated she did not follow the recipe or use the proper measurements documented for the eight residents on a pureed diet, used liquid from the baked potatoes instead of milk, and was not formally trained on puree meal preparation. The puree recipe book reviewed by surveyors did not include a recipe recommendation for hamburger helper preparation, and the dietary manager stated staff were not using the puree recipe book while preparing meals and were instead being verbally instructed on what ingredients to use.
Food Storage and Dishwashing Sanitation Failures
Penalty
Summary
Food was not stored, prepared, and sanitized in accordance with professional standards in the kitchen serving 104 residents on oral diets. During the initial kitchen tour, surveyors observed a thick buildup of ice on the freezer floor with icicles hanging from boxes stored on the shelves. Several bags of frozen foods, including French fries, hamburger patties, mixed vegetables, and meats, were stored in a box on a shelf without an expiration date or opened/used-by date documented. In the refrigerator, an opened loaf of bread, a few slices of molded cheese, an opened box of pancakes, and a staff member's personal medications were observed together. Surveyors also observed the three-compartment sink with pots and pans being washed by staff using a bottle of bleach as sanitizer. The dishwasher was observed running while one staff member prewashed dishes, cups, and utensils and another hand-dried them with a dish towel. Staff interviews confirmed the dishwasher was not working correctly, the chemicals for the 3-compartment sink had been hooked up incorrectly, and the dishwasher temperature gauge was not registering while chemical testing strips did not give a reaction. The Dietary Manager stated staff had been hand washing dishes before placing them into the dishwasher and adding bleach to assist with sanitizing, and the Corporate Manager stated staff were instructed to continue using bleach and run another cycle until the repairman arrived.
Failure to Maintain QAPI Documentation and Program Oversight
Penalty
Summary
The facility failed to maintain an effective QAPI program that systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Based on record review and staff interviews, the facility could not produce any documentation for review related to its QAPI program, including meeting attendance records, and the QAPI policy was also not produced. The Administrator stated on interview that the facility does not maintain QAPI documentation because it has not been documented as required, that the QAPI program is not effective, and that there is currently no tracking or trending of data for trends. She further stated that most issues are addressed during the morning clinical meeting. The deficient practice was identified as affecting 109 residents.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration error rates were found to be 38.46% based on 26 observed opportunities with 10 errors, exceeding the facility policy requirement that medication errors remain below 5%. During observation of medication administration on the C Wing, an LPN administered multiple medications to one resident by mouth, including clopidogrel, divalproex sodium, lactobacillus, mirabegron, Actos, Seroquel, carvedilol, gabapentin, buspirone, and paroxetine. Review of the resident’s February 2026 physician orders showed these medications were ordered to be given via G-tube, and the MAR confirmed the orders were transcribed correctly. The observation and record review showed the medications were given by the wrong route. In addition, Seroquel was administered at 200 mg even though the order was for 400 mg. The LPN confirmed she gave the medications by mouth and stated the resident had been sneaking and eating and that the facility was trying to get the G-tube removed, but acknowledged she should have followed the orders because the resident could have aspirated. The ADON and Administrator stated that nurses were expected to follow physician orders and the rights of medication administration.
Medications Given by Mouth Instead of via G-Tube
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident with a G-tube. The resident was readmitted with diagnoses including COPD with acute exacerbation, hyperlipidemia, dysphagia, major depressive disorder, and altered mental status. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and the care plan identified the resident as NPO with tube feeding and aspiration precautions due to alteration in nutrition related to the G-tube and significant weight loss concerns. The physician orders directed multiple medications to be given via G-tube, including clopidogrel, divalproex, gabapentin, lactobacillus, mirabegron ER, paroxetine, and quetiapine, along with enteral feeding orders. During medication administration observation, an LPN gave all medications by mouth instead of via the G-tube. The LPN confirmed that the medication cards and physician orders were for G-tube administration and stated she gave the medications by mouth because the resident had been sneaking and eating and the facility was trying to get the resident cleared to remove the G-tube. An APRN later confirmed that the resident should have been receiving medications via the G-tube as ordered.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during meal service on two of its halls, D Hall and E Hall. Observations revealed that CNAs did not sanitize their hands between resident contacts while serving meals. Specifically, CNA BB was seen not sanitizing her hands after leaving a resident's room and handling meal trays, while CNA HH also failed to sanitize her hands between serving meals to different residents. Both CNAs acknowledged their failure to follow hand hygiene protocols, citing forgetfulness and a desire to expedite meal service as reasons for their actions. The Director of Nursing confirmed that the expectation was for staff to sanitize their hands between resident contacts to prevent the spread of infections. Additionally, the facility did not have an effective water management program to prevent the growth of Legionella and other waterborne pathogens. The policy for Legionella surveillance was in place, but the facility could not provide a current water management program. The Maintenance Director and Environmental Services Director admitted that the previous Maintenance Director, who had left the facility, took all documentation related to the water management program. They were in the process of developing a new program, but at the time of the survey, no current program was in place, posing a risk of waterborne illnesses to residents.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as evidenced by observations and staff interviews. On three of five halls and one of two shower rooms, issues such as patched walls, stained ceiling tiles, missing floor tiles, scuffed walls, and foul odors were noted. Specifically, the A Hall had patched walls and stained ceiling tiles, while the C Hall shower room had missing floor tiles, scuffed walls, and a foul odor. These conditions were confirmed by the Administrator and Maintenance Director during observations. Additionally, the D Hall was reported to have an unpleasant odor, particularly of urine, which was strongest near specific rooms. Interviews with staff, including a CNA and the DON, confirmed the presence of the odor and identified bins containing soiled linens and incontinence pads as potential sources. The Environmental Services Lead noted that the bins, which contained incontinence trash and dirty laundry, were unique to the D Hall and were believed to contribute to the odor. The Administrator acknowledged the issue and expressed expectations for the facility to be odor-free.
Unauthorized Bedside Medication Storage
Penalty
Summary
The facility failed to ensure that unauthorized medications were not stored at the bedside for one of the sampled residents, identified as R10. The facility's policy on Bedside Medication Storage allows residents to self-administer medications only if there is a written order from the prescriber and the resident's self-administration skills have been assessed and deemed appropriate. However, R10's medical records did not contain any physician's order for self-administration of medications, nor was there a care plan area for self-administration. Despite this, a bottle of Gold Multi + Vita-Lea with Vitamin K was found on R10's bedside table, which R10 had been taking since before admission to the facility. R10 stated that the staff was aware of the vitamins. Interviews with facility staff, including a CNA, an LPN, the DON, and the Administrator, confirmed that medications are not allowed at the bedside unless specifically authorized by a physician. The LPN removed the unauthorized medications from R10's bedside, and the DON emphasized the risk of overdose if medications were left at the bedside. The Administrator reiterated that medications at the bedside posed a risk and that staff members were expected to remove any medications they observed to ensure resident safety.
Failure to Provide Bed Hold Notices for Hospitalized Resident
Penalty
Summary
The facility failed to provide written bed hold notices for a resident who was hospitalized, as required by their policy. The facility's undated Bed Hold Policy outlines the need for clear guidelines regarding payment sources to maintain or hold a resident's bed during hospital stays. However, during a review, it was found that the facility did not issue a bed hold notice for a resident who was transferred to a hospital on two separate occasions. The resident was initially transferred due to urgent medical needs and later due to abnormal breathing, with both instances documented in the Nurse's Notes. Interviews with the Business Office Manager and the Administrator confirmed that no bed hold notice was provided for the resident's hospital transfers. The Administrator mentioned that families are informed of the bed hold policy at admission, and it is included in the admission packet. However, the Business Office Manager admitted that she does not provide a bed hold policy when a resident is transferred to the hospital, which led to the deficiency identified in the report.
Inaccurate MDS Coding for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments were accurately coded to reflect the resident's status at the time of the assessment for one of the sampled residents, identified as R42. R42 was admitted with diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. The Annual MDS for R42 incorrectly documented that the resident had not been evaluated by Level II PASRR, despite a PASRR Level II being completed on 9/21/2023. This discrepancy was confirmed by the MDS Coordinator during an interview. Further interviews revealed that Registered Nurse (RN) GG, who was responsible for signing off on the MDS assessments, did not verify the accuracy of the information. The Administrator acknowledged that RN GG's role was to confirm the completion of the MDS but expected the information to be accurate. The Administrator also confirmed that the facility did not have a specific MDS policy and relied on the Resident Assessment Instrument (RAI) guidelines. This lack of accurate coding on the MDS assessment had the potential to affect the assessment of R42's care needs.
Deficient ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, specifically fingernail care and oral hygiene, for two residents. Resident 11, who has severe cognitive impairment and requires substantial assistance with ADLs, was observed with long fingernails and a dark substance underneath them. Despite the resident's preference for shorter nails, it was noted that they had not been cut for a month. A Certified Nurse Assistant (CNA) confirmed the condition of the nails and acknowledged the need for cleaning and trimming. The Director of Nursing (DON) stated that nail care is expected to be part of ADL care. Resident 2, who has no cognitive deficit but is dependent on assistance for all ADLs due to impairments in both upper extremities, was found to have a foul odor from the mouth, indicating a lack of oral hygiene. The resident reported not receiving assistance with brushing teeth for over two weeks, although mouthwash was provided. A CNA confirmed that while mouthwash was offered, assistance with brushing teeth was not provided. The DON emphasized the expectation for staff to assist with oral care daily and as needed.
Failure to Document Controlled Medication Shift Counts
Penalty
Summary
The facility failed to ensure that controlled medication shift counts were properly documented with nurse signatures on the D Hall Medication Cart. This deficiency was identified through observations, staff interviews, and a review of the facility's policy on Controlled Substance Prescriptions. The policy, revised in August 2020, mandates that medications classified as controlled substances by the DEA and state law must adhere to specific ordering, receipt, and record-keeping requirements. However, an observation on December 4, 2024, revealed that there were 28 missing signatures out of 112 opportunities for controlled-substance shift counts between September 29, 2024, and October 27, 2024. These missing signatures indicated a failure to document the shift counts for incoming and outgoing nurses, which is a critical step in ensuring the availability and accountability of controlled medications. Interviews with facility staff further highlighted the deficiency. The Nursing Supervisor expressed that her expectation was for nurses to count narcotics and document the count by signing the controlled substance sheet at each shift change. She noted that discrepancies in controlled medication counts could result in residents not receiving their medications if they were missing. Similarly, the Director of Nursing confirmed that controlled medications should be counted by nurses at shift change, and the controlled substance sheet should be signed by both the oncoming and off-going nurse to verify the accuracy of the count. The lack of adherence to these procedures posed a potential risk to the availability of residents' controlled medications.
Expired Medications Found in Storage Room
Penalty
Summary
The facility failed to ensure that expired medications were removed from one of its medication storage rooms, as observed during a survey. The facility's policy, revised in August 2020, mandates that all expired medications be removed from active supply and destroyed according to the policy. However, during an observation on December 4, 2024, 14 blister-pack medications with an expiration date of July 2024 were found on the counter in the Front Hall Medication Storage Room. Additionally, a bottle of vitamin D 250 mcg with an expiration date of October 2024 and a bottle of vitamin D 400 IUs with an expiration date of November 2024 were also found. These expired medications were verified by an LPN, who acknowledged that they should have been discarded. Interviews with facility staff further confirmed the oversight. A Nursing Supervisor confirmed the presence of the expired medications and stated that they should have been placed in a sealed bag and labeled for pharmacy pickup. The Director of Nursing expressed that the expectation was for nurses to remove expired medications from the medication room to prevent residents from potentially receiving them. The facility census at the time was 97 residents, indicating a significant risk of exposure to expired medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sylvania
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Bethany | 17.4 mi | ★★★★★ | 0 | 0 |
| Westwood Healthcare And Rehabilitation | 21.7 mi | ★★★★★ | 0 | 0 |
| Heritage Inn Health And Rehabilitation | 21.8 mi | ★★★★★ | 0 | 0 |
| Brown's Health And Rehabilitation | 22.4 mi | ★★★★★ | 4 | 0 |
| Eagle Health & Rehabilitation | 22.7 mi | ★★★★★ | 0 | 0 |
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