Pine Forest Car Center For Rehab & Healthcare

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision to prevent accidents for 10 of 12 residents reviewed for accidents. Several residents were allowed to go out on pass into the community without documented evidence of a physician order, without documented assessment of their physical and mental ability to do so safely, and without documented safety assessments. One resident and another resident went out together on multiple occasions, and on one occasion did not return at the expected time and were found the next day. Another resident with psychoactive substance abuse and psychoactive substance induced anxiety disorder also went out on pass multiple times and was signed out as their own responsible party. Resident #1 had diagnoses including dementia, strange and inexplicable behavior, and homelessness, and the MDS documented moderate cognitive impairment, need for supervision, touch assistance for ambulation, and risk for wandering. The resident had previously been brought to the hospital after being found walking along a highway looking for Resident #2, who was identified as the resident’s boyfriend. Resident #1’s care plan addressed wandering and exit seeking, and the resident was prescribed quetiapine three times daily for mild dementia, but the MARs showed frequent refusals of the medication across July, August, September, and early October 2025. There was no documented evidence that the repeated missed doses were brought to the attention of medical practitioners. On 09/30/2025, Resident #1 left the facility with Resident #2 on an out-on-pass form listing Resident #2 as the responsible party, with an expected return time of 3:00 PM. The residents did not return at the designated time and were found on 10/01/2025 at approximately 10:00 AM. Facility notes documented that Resident #1 returned from an unauthorized out on pass, walked around the unit concerned about Resident #2, and refused meals. Staff later documented that Resident #1 frequently came out of the room at night with a backpack asking where Resident #2 was, frequently refused medication, and became more focused on finding Resident #2 when not taking quetiapine. The DON, DSW, Medical Director, and Psychiatric Nurse Practitioner each stated that Resident #2 leaving the facility was a significant emotional change for Resident #1 and that Resident #1’s mood should have been assessed at that time. After Resident #2 left, there was no documented psychosocial assessment of Resident #1’s mood related to that significant emotional change. Later, Resident #1 was found on the ground at the back of the building after removing the air conditioner from a window, and the incident was documented as a fall involving sitting on the stairs/ground. Resident #1 was then hospitalized and readmitted with new diagnoses including suicide attempt and multiple fractures. The record also showed no documented physician assessment for depression or suicide from readmission through the following week, and multiple staff interviews confirmed that Resident #1 should have been assessed for mood and suicide risk when Resident #2 left and again when the resident returned with the new suicide attempt diagnosis.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of dementia, mental illness, and homelessness, who was assessed as having wandering and exit-seeking behaviors, did not receive appropriate treatment and services following a significant emotional event. After the discharge of a close companion from the facility, the resident exhibited increased wandering, emotional distress, and refusal of medications. Despite these changes, there was no documented evidence that a psychosocial assessment was completed to address the resident's altered mental and psychosocial state. The resident's care plan identified risks related to cognitive impairment and adjustment issues, and interventions included monitoring medication effectiveness and providing support for psychosocial wellbeing. However, the resident frequently refused prescribed antipsychotic medication, and the high rate of missed doses was not communicated to medical practitioners. Additionally, after the resident returned from an unauthorized absence and following the discharge of their companion, staff did not assess the resident's mood or risk for depression or suicide, despite facility policies requiring such assessments after significant emotional changes. The situation escalated when the resident was found on the ground outside the facility after removing an air conditioner from a window, resulting in multiple fractures and hospitalization. Upon readmission with a new diagnosis of suicide attempt, there was still no documented assessment for depression or suicide risk until several days later. Interviews with staff and medical personnel confirmed that the resident's emotional state should have been assessed after both the companion's discharge and the resident's readmission, but these assessments were not completed in a timely manner.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure that a resident's physician was properly consulted following a significant change in the resident's physical status. The resident, who had diagnoses including dementia, strange and inexplicable behavior, and a history of homelessness, was at risk for wandering and had moderate cognitive impairment. The resident was found outside on the ground at the back of the building after falling from a third-story window and was subsequently sent to the hospital via 911. Facility policy required prompt notification and consultation with the resident's physician in the event of an accident resulting in injury or with the potential to require physician intervention. Although a nursing progress note indicated that the Medical Director was made aware of the incident, the Medical Director later stated they were not informed of the resident's transfer to the hospital until the resident was readmitted with multiple fractures. The nurse supervisor reported sending a message via a messaging application but did not follow up to confirm receipt, and there was no documented evidence of the message due to the application's message retention policy. Interviews with facility staff, including the Director of Nursing Services, confirmed that the physician should have been informed of the change in the resident's condition. The Medical Director stated that staff were instructed to call if a message was not acknowledged, but this protocol was not followed. As a result, the required physician consultation did not occur at the time of the significant change in the resident's status.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the New York State Department of Health as required by federal and state regulations. Two residents, both with significant medical and cognitive conditions, were involved in separate incidents where the facility did not notify the appropriate authorities within the mandated timeframes. In the first incident, two residents went out on pass and did not return at the expected time. The facility did not report their absence to the Department of Health until several hours after they were located, exceeding the required two-hour reporting window. There was also no documented evidence that the police were notified when the residents did not return as scheduled. In the second incident, one of the same residents, who had dementia and a history of wandering, exited the building through a third-story window after removing an air conditioner and sustained multiple injuries requiring hospitalization. The facility did not report this serious incident to the Department of Health within the two-hour timeframe, as required for events involving serious bodily injury. The delay was attributed to the staff managing emergency services and conducting internal interviews, as well as lack of immediate computer access for reporting. Additionally, the facility lacked documentation showing that either resident was assessed for capacity to go out on pass, had a physician's order for the pass, or had a comprehensive care plan addressing outings. Interviews with the DON and Administrator confirmed awareness of the reporting requirements but acknowledged the incidents were not reported within the required timeframes. The facility's own policies required prompt notification to authorities, but these were not followed in the cited events.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with diagnoses including dementia, behavioral issues, and homelessness repeatedly refused their prescribed antipsychotic medication, Quetiapine (Seroquel). Despite these refusals, there was no documented evidence that the psychiatric nurse practitioner, who prescribed the medication, implemented an intervention plan or notified the primary care physician about the ongoing refusals. The resident's medication administration records showed a significant number of missed doses over several months, with refusals increasing over time. The facility's policies required that a physician, physician assistant, nurse practitioner, or clinical nurse specialist provide orders for the resident's immediate care and needs, and that the physician take an active role in supervising resident care. However, the psychiatric progress notes only indicated that the resident should continue the current medication regimen, with no mention of the refusals or any plan to address them. The psychiatric nurse practitioner acknowledged being aware of the resident's inconsistent medication intake but did not know the exact number of refusals and did not take further action. Interviews revealed that the primary care physician was unaware of the extent of the missed doses and stated that the medication would not be effective with so many missed doses, potentially impacting the resident's judgment. The psychiatric nurse practitioner confirmed that no changes were made to the medication regimen, citing the resident's right to refuse medication. The lack of communication and intervention regarding the resident's repeated medication refusals led to the finding that the facility did not ensure the resident was under appropriate medical supervision as required by regulation.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified that the facility failed to ensure all drugs and biologicals were stored in a locked compartment and accurately labeled, as required by facility policy and regulation. During an observation, a treatment cart on the first floor was found unlocked with the second drawer open and treatment medications visible, while no staff were present. The facility's policy states that all drugs and biologicals must be stored in locked compartments and only authorized personnel should have access to the keys. During a medication pass, medications must be under the direct observation of the administering staff or locked in the storage area or cart. A registered nurse acknowledged that the treatment cart's lock was broken and admitted to accepting the cart in that condition at the start of their shift, despite knowing it should not have been used without a functioning lock. The Director of Nursing Services confirmed that all treatment carts should be locked and, if the lock is not working, the cart should not be in use. The deficiency was identified for one of two facility treatment carts, specifically the one observed outside a resident's room.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when the facility failed to maintain an effective infection prevention and control program as required by federal regulations. Specifically, a resident with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) infection in a foot wound was placed on contact precautions, as documented in the care plan and supported by multiple physician orders. The orders specified the use of enhanced barrier precautions, including the use of personal protective equipment (PPE) such as gloves, gowns, and face masks during resident care activities. The facility's policies also required staff to adhere to these precautions and to report any breaches in infection control practices. Despite these requirements, observations revealed that staff did not consistently follow the prescribed infection control measures. During one observation, a registered nurse supervisor exited the resident's room wearing only a mask, which was then improperly disposed of by crumpling it and placing it in a pocket, without performing hand hygiene. Additionally, the same nurse was observed providing care to another resident without wearing any PPE. Interviews with the staff involved confirmed that they were not wearing gowns while providing wound care to the resident on contact precautions, and acknowledged that this was a breach of protocol that could lead to contamination. The Director of Nursing Services confirmed that signage was present on the resident's door indicating the required PPE for contact precautions, and stated that all staff should wear appropriate PPE before entering rooms of residents on contact precautions. However, there was no documented evidence of a physician's order to discontinue contact precautions for the resident, and the required infection control practices were not followed during the observed care activities. This failure to adhere to established infection prevention and control protocols resulted in a deficiency citation for the facility.

Penalty

Inspection fine: $15,733

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that comprehensive person-centered care plans were developed and implemented with measurable objectives and timeframes for residents who went out on pass. Eleven residents were reviewed for accidents, and all eleven had out-on-pass documentation showing multiple trips off the unit, but the record did not show that each resident had a care plan addressing the medical and nursing needs associated with those passes. Facility staff stated that residents going out on pass required a physician order and that care plans should be updated, but the records reviewed did not show that this occurred for the residents identified. Resident #1 had diagnoses including dementia, strange and inexplicable behavior, and homelessness, with moderate cognitive impairment, supervision/touch assistance needed for ambulation, and wandering risk. Resident #2 had bipolar disorder, type 2 diabetes, chronic multifocal osteomyelitis of the right foot and ankle, and difficulty walking, and was admitted for post-operative care after a right great toe amputation. Resident #5 had cellulitis of the left lower limb, psychoactive substance abuse with psychoactive substance-induced anxiety disorder, and difficulty in walking, with intact cognition and use of a walker and wheelchair. The EMR review did not show physician orders for out-on-pass for these residents, and no comprehensive person-centered care plans were documented for their repeated passes. The deficiency also involved room changes and a behavioral health diagnosis. Resident #1, Resident #2, and Resident #5 each had room changes or new roommates, but the record did not show comprehensive person-centered care plans with measurable objectives and timeframes related to those changes. Resident #5 also had a diagnosis of psychoactive substance abuse with psychoactive substance-induced anxiety disorder, yet no comprehensive person-centered care plan was developed for that diagnosis. Staff interviews reflected that nursing, social work, or the interdisciplinary team were responsible for updating care plans after room changes or out-on-pass events, but the documentation reviewed did not show that these care plans were completed for the residents identified.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident experienced a significant, unplanned weight loss, dropping from 190 pounds in July to 168 pounds in August, representing an 11.5% loss in one month. This exceeded the CMS guideline for significant weight loss, yet there was no documented evidence that the dietician implemented new nutritional interventions to address the decline prior to the survey. The facility's policy required specific actions when significant weight loss is detected, such as weekly and monthly weights, review of food intake, initiation of a 3-day caloric count, and identification of possible causes, but these steps were not documented as completed. The resident, who had diagnoses including dementia, anxiety disorder, and type 2 diabetes, required supervision or assistance with eating and other activities of daily living. Despite a care plan goal to prevent significant weight changes and ensure adequate meal and supplement intake, records showed the resident was not consuming full meals and often only ate part of a sandwich when offered as an alternative. Staff interviews confirmed that the resident was not eating the hot meals provided and that this was known among staff, but there was no evidence of escalation or intervention by the dietician or nursing team. Documentation from the dietician and changes to the plan of care were absent during the period of weight loss. The DON stated that a calorie count was not initiated because meal intake records indicated the resident was eating 50% of meals, though direct observation and staff interviews contradicted this. The medical director indicated that, in cases of significant weight loss, a calorie count and further investigation would typically be pursued, but there was no evidence these steps were taken for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that on the second floor, a locked dementia care unit, a resident's bedside table contained a bottle of over 30 multivitamin tablets and a 16-ounce bottle of 91% isopropyl alcohol, both accessible to the resident. The resident, who has a diagnosis of dementia, anxiety disorder, and type 2 diabetes, was unable to identify the pills or the alcohol, mistaking the alcohol for water. The resident's care plan documented short and long-term memory loss and included interventions to ensure safety, but there was no care plan or physician order permitting self-administration of medication. Staff interviews confirmed that the LPN was unaware of how the items came to be at the bedside and stated that the resident should not have access to either the alcohol or the vitamins. The DON also confirmed that no medication or alcohol should be accessible to residents on the dementia unit. The presence of these items in the resident's room, without staff knowledge or appropriate care planning, constituted a failure to maintain an environment free of accident hazards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have deficiencies related to the means of egress as per the NFPA 101 Life Safety Code, 2012 Edition. Specifically, a ramp located on the second floor between the Old Building and the New Wing did not comply with the dimensional criteria set forth in the code. The ramp had a slope of 15 inches in height over a length of 10.3 feet, which exceeds the permissible slope of 1 inch in 8 feet. At the time of the survey, no work had been observed to address this issue, despite a time-limited waiver being granted to correct it. Additionally, a corridor on the first floor, adjacent to the Administrator's office, was found to be reduced to 40 inches in clear width, which is below the required minimum of 48 inches for corridors serving as means of egress from patient sleeping rooms. This corridor served as exit access for five occupied resident sleeping rooms and one nurse office. The arrangement of emergency exits at the end of this corridor did not comply with the Life Safety Code requirements, as they were located opposite each other with a distance of approximately 28 feet between them, potentially allowing both exits to be blocked by a single fire or emergency condition. The facility had been granted a CMS Time Limited Waiver to address these issues, set to expire on July 1, 2025. However, at the time of the survey, the facility had not demonstrated substantial progress in addressing the deficiencies. The owner stated that plans were being drawn by an architect, but permits had not yet been obtained, and no construction work had commenced. The facility's Plan of Correction included contracting with an architectural firm to reconfigure the ramp and modify the corridor width, but there was no evidence of progress on these plans.

Plan Of Correction

Plan of Correction: Approved April 22, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. Pine(NAME) Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025. 3a. The facility will require a time limited waiver for three years, ending 2/7/2028, to complete construction to widen the corridor to 48 inches minimum. The facility is currently investigating means to widen the existing first floor corridor as it is located between a masonry chimney and apparent bearing wall. The existing LRA shall be updated accordingly to include this work. It’s anticipated that the LRA will be updated by 8/7/2025. Following LRA modification approval, construction drawings will be prepared by 2/7/2026. Local approvals are expected to be obtained by 8/7/2026. Construction is anticipated to be complete by 10/7/2027. Signoffs are anticipated to be complete by 2/7/2028. 3b. While the facility has a time limited waiver in place, upon further review of the existing conditions during production of construction drawings, the Architect determined that the existing ramp slope is compliant. An existing ramp is permitted to have a maximum slope of 1:8, or 12.5%. The existing ramp was recorded to measure 15 inches in height and 10.3 feet in length. The existing ramp slope is calculated to be 12.14%, which is less than 12.5% maximum permitted. 3c. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. fire watches 2. additional fire drills 3. testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. provide additional extinguishers 7. properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required. 8. During construction, facility will perform frequent observations of the work areas to monitor resident safety. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11. The Administrator is responsible for the correction of this deficiency by 4/1/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to be non-compliant with NFPA 101: 19.1.6.1 during a Life Safety Code recertification survey. The West building, referred to as the Old Building, was identified as a two-story, fully sprinklered Type V (000) construction, which does not meet the required Type V (111) construction standards. The facility had been granted a CMS Time Limited Waiver (TLW) to address this issue, which is set to expire on July 1, 2025. However, as of the survey date, the facility had not yet obtained the necessary permits from the local jurisdiction, and construction had not commenced. The architect was still in the process of drawing plans, and additional smoke detectors had been installed, but these actions were insufficient to bring the building into compliance. The facility's Plan of Correction for tag K161, cited during a previous Life Safety Code survey, included reconfiguring the existing second-floor corridor ramp to achieve a compliant slope and constructing an addition to accommodate the level change. Despite having a timeline for obtaining town approval, preparing final construction drawings, and completing construction, there was no evidence that any of these milestones had been achieved at the time of the survey. The facility had contracted with an architectural/engineering firm to conduct a Fire Safety Evaluation System (FSES) after the installation, but the construction phase had not yet begun, leaving the facility out of compliance with the required safety standards.

Plan Of Correction

Plan of Correction: Approved March 17, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. Pine(NAME) Center for Rehabilitation and Healthcare has an approved CMS time limited waiver that expires on 7/15/2025. 3a. The facility is fully sprinkled, and hard-wired detectors, connected to a central alarm system, are installed in each resident room and throughout the facility. Interior finishes on walls and ceilings within the means of egress and within all resident rooms are Class A materials. The facility will implement the following additional measures to mitigate the risks to residents and staff: 1. Fire watches 2. Additional fire drills 3. Testing the fire alarm system more frequently, immediately replacing non-functioning equipment 4. Identify and mitigate the risks such as extension cords, amount of ABHR and their locations 5. Conduct daily rounds to ensure all fire and smoke doors are functioning and not propped open. Any open doors are on electronically supervised hold opens and doors will shut when alarms are activated 6. Provide additional extinguishers 7. Properly store O2 cylinders in properly rated rooms. Thresholds will be verified weekly to ensure thresholds are not being exceeded. Ensure corridors remain unobstructed to allow for evacuation when required. 8. The facility already has enhanced training for fire safety with an additional focus on awareness of fire alarms, location of fire/smoke barriers and evacuation procedures. 9. Facility has developed an audit/daily rounds tracking sheet to ensure the interim life safety measures that were put into place are being completed while the deficiency exists. 10. Administrator will report any updates at the next quarterly QA meeting. 11. The Administrator is responsible for the correction of this deficiency by 4/1/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that fire drills were conducted at unexpected times and under varying conditions, as required by the 2012 NFPA 101: Life Safety Code. Specifically, the document review revealed that in six out of twelve fire drills, the condition that caused the simulated fire drill and fire alarm activation was not documented. Additionally, the fire drills were conducted at similar times across different shifts, with three out of four morning shift drills occurring around 10:00 AM and all four night shift drills occurring between 11:00 PM and 6:15 AM. Furthermore, the fire drill logs from the past year did not include the scenarios simulated during the drills, making it impossible to determine if the drills were conducted under varying conditions. This lack of documentation and variation in drill timing was acknowledged by the facility's Administrator and owner during the exit interview. The failure to conduct fire drills at unexpected times and under varying conditions, as well as the lack of detailed documentation, constitutes a deficiency in compliance with the NFPA 101 standards.

Plan Of Correction

Plan of Correction: Approved March 10, 2025 Pine (NAME) Center for Rehabilitation and Healthcare provides the following Plan Of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The EVS Director will conduct fire drills along with scenarios for each fire drill on all three shifts and alternate the times within the shifts, as well as the dates within the month. 4. The Administrator will review with the EVS Director the proposed times and dates of the fire drill to ensure the randomization of the dates and times that the fire drills are being conducted. 5. The Administrator will review the fire drill log book on a quarterly basis to ensure fire drills have been scheduled/conducted on random times/dates. 6. The Administrator will report the findings of his quarterly fire drill audit at the quarterly QA/QAPI meeting. 7. The Administrator and EVS Director will be responsible for the correction of this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a timely and thorough investigation of an alleged abuse incident involving a resident. On December 28, 2024, a resident reported being scratched by a Certified Nursing Assistant (CNA) during morning care. However, there was no documented evidence that an investigation was initiated until December 30, 2024, when the resident's representative reported the incident to the Director of Nursing Services. The facility's policy requires that all accidents or incidents involving residents be reported immediately and an Accident/Incident Report be completed on the shift in which the incident occurred, but this protocol was not followed. The resident involved had a history of Bipolar Disorder and Urinary Tract Infection and was assessed to have moderately impaired cognition. The resident required assistance with daily activities and had no functional limitations in the range of motion. On the day of the incident, the resident alleged that a CNA squeezed their fingers and scratched their buttocks during care. Despite the resident's complaints, the initial examination by a nurse found no visible injuries, and the resident's skin was noted to be intact. The resident continued to insist on being scratched, but no immediate investigation or documentation was made by the staff present at the time. Interviews with the staff involved revealed inconsistencies in the handling of the incident. The CNAs involved denied the allegations, and the Registered Nurse who assessed the resident failed to document their findings or initiate an investigation. The Director of Nursing Services was only made aware of the situation two days later, highlighting a significant delay in addressing the resident's allegations. This delay in response and lack of documentation contributed to the deficiency identified during the survey.

Plan Of Correction

Plan of Correction: Approved March 5, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F610. SW met with resident #55 on 2/28/2025 and offered psychological and psychiatric services. Resident declined the services, and resident denied any emotional distress. RN #2 was re-educated on 3/01/2025 on the policy and procedure on initiating abuse/mistreatment/neglect investigation and reporting guidelines and on proper documentation. Certified Nurses Assistant #4 and #5 was re-educated on 2/26/2025 on the policy and procedure of abuse/mistreatment/neglect and exploitation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by the alleged deficient practice. Facility did an audit/review on 2/25/2025 on investigations of allegations, and no potential reportable allegations of abuse were found. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Abuse Reporting and Investigating was reviewed by DNS, Admin, and Social Worker and no updates were made. All RN Supervisors were re-educated on 3/01/2025 on the Policy and Procedure for Abuse Reporting and Investigation Policy by the DON/designee. New hires will be trained during the onboarding process. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure allegations of abuse, neglect or mistreatment are investigated immediately as required. Any adverse findings will be immediately corrected accordingly. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident who experienced an opioid overdose. Resident #55, who had diagnoses including Delusional Disorder, Bi-Polar Disorder, and Alcohol Abuse, was transferred to the hospital due to unresponsiveness and was readmitted with a diagnosis of opioid overdose. Despite the facility's policy requiring Naloxone availability and standing orders for its administration, there was no documented evidence of a care plan with appropriate interventions to prevent further opioid overdoses. Interviews revealed that the Minimum Data Set Coordinator and the Director of Nursing Services acknowledged the absence of a care plan addressing the opioid overdose. The Minimum Data Set Coordinator stated that they or the admission nurse could have initiated such a care plan, and the Director of Nursing Services confirmed that the responsibility lay with the Minimum Data Set Coordinator, with Registered Nurse Supervisors as a backup. The lack of a care plan specifically addressing the opioid overdose was identified as a deficiency during the survey.

Plan Of Correction

Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction to address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F656. Resident #55 care plan was updated on 2/10/2025 by MDS Coordinator to include [DIAGNOSES REDACTED]. All residents on opioids and/or have a history of opioid overdose have the potential to be affected by this alleged deficient practice. A full house audit was conducted on all residents by MDS Coordinator/DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that addresses their risk for opioid overdose and have appropriate goals and interventions to prevent potential opioid overdose. Any negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Comprehensive Care Plan was reviewed by MDS Coordinator/ DON/ Social Worker, Coordinator/DON/social worker. The DON/MDS Coordinator educated the nursing staff and IDT on 2/25/2025 about “Comprehensive Care Plans” with emphasis on developing a person-centered care plan for those residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression, with appropriate goals and interventions to prevent further potential opioid overdose. Care plans were immediately updated to reflect an accurate, person-centered plan of care for the residents based upon the residents assessed condition and needs, if required. Staff were reminded of the potential consequences to both the residents and staff if the policy is not followed. Any staff found responsible for the deficient practice will be referred to the DON for counseling. An audit was conducted on all residents by MDS Coordinator /DON on 2/27/2025 to ensure that residents with moderate to high-risk index for opioid overdose or serious opioid-induced respiratory depression have a care plan that accurately reflects their physical and mental health needs and assures their needs are addressed and met. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The MDS Coordinator /DON/Designee will audit 5 resident care plans x 4 weeks, then 5 resident care plans monthly x 3 months to ensure that residents with moderate to high risk index for opioid overdose or serious opioid-induced respiratory depression have a person-centered care plan addressing potential for opioid overdose with appropriate goals and interventions to prevent further potential opioid overdose. Any adverse findings will be immediately corrected. Audit findings will be presented to the QA Committee monthly meetings x 6 months. The results of these audits will be reviewed in the monthly QA Committee monthly meetings for 6 months or until 100% compliance is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated. 5. The date for correction and the title of the person responsible for correction of each deficiency: DON is responsible for the compliance by 03/10/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that services provided met professional standards of quality, as evidenced by the improper administration of Heparin injections to a resident. The resident, who had a diagnosis of Functional Quadriplegia and an intact cognitive status, was receiving Heparin subcutaneously twice daily as a prophylactic measure. However, the nursing staff did not rotate the injection sites as required by the facility's policy, leading to repeated injections in the same area of the lower left abdomen. This was confirmed through a review of the Medication Administration Record, which showed multiple instances of consecutive injections in the same site over several days. During an observation, the resident was found to have a quarter-size ecchymosis on the lower left abdomen, indicating potential tissue damage from the repeated injections. Interviews with the nursing staff and the Director of Nursing Services confirmed that the injection sites were not rotated as per the policy, and the nurse responsible could not provide a reason for this oversight. The physician also acknowledged that failure to rotate injection sites could result in bleeding, pain, and tissue damage, further highlighting the deficiency in adhering to professional standards of care.

Plan Of Correction

Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F658. Resident #20 was reassessed by RN supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated ON 2/26/2025 to include rotating sites with each administration. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON and no updates were made. All Nurses were re-educated on 3/01/2025 by DON/Designee on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months on all residents on [MEDICATION NAME] to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure pharmaceutical services met the needs of each resident by not adhering to professional standards of practice for administering medications. Specifically, Resident #21 was prescribed Heparin Sodium Injection Solution and the nursing staff did not rotate the subcutaneous injection sites as required. The facility's policy and procedure for injection site rotation, as well as professional guidelines, emphasize the importance of rotating injection sites to prevent complications such as bruising. Resident #20, who was admitted with functional quadriplegia and had an intact cognitive status, received Heparin injections to the same site on the lower left abdomen over multiple days. This was documented in the Medication Administration Record for January and February 2025. During an observation, a quarter-size bruise was noted on the resident's abdomen, and the resident confirmed they did not monitor the injection sites. Interviews with the nursing staff and the Director of Nursing Services revealed that the injection site was not rotated as required, which could lead to tissue damage and discomfort.

Plan Of Correction

Plan of Correction: Approved March 3, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan of Correction. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F755. Resident #20 was reassessed by the RN Supervisor/DON on 2/10/2025 and showed no signs or symptoms of injury due to alleged deficient practice. Resident #20 [MEDICATION NAME] order was updated on 2/26/2025 to include rotating sites with each administration. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving [MEDICATION NAME] have the potential to be affected by the alleged deficient practice. Facility-wide audit/review was done on 2/10/2025 by DON to identify residents receiving [MEDICATION NAME] injections and no other resident was found with [MEDICATION NAME] orders. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Policy and Procedure for Subcutaneous injections reviewed by DON/Designee and no updates were made. All Nurses were re-educated on 3/01/2025 by the DON on the Policy and Procedure of Subcutaneous injection administration including rotation of sites for each administration. New hires will be trained during the onboarding process. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. An audit will be conducted by DON/Designee weekly for 4 weeks and monthly for 3 months to ensure injection sites of [MEDICATION NAME] administration are rotated as required. Any adverse findings will be immediately corrected. Any staff found responsible for the deficient practice will be referred to the DON for counseling. Results of audits will be reviewed in QAPI committee meeting to monitor for compliance. The consultant pharmacist will monitor externally for appropriate site rotation based on administration records and will report negative findings to DON. The date for correction and the title of the person responsible for correction of each deficiency: DON will be responsible for implementation and compliance by 03/10/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During a kitchen inspection, it was observed that several food items in the walk-in refrigerator and freezer were not properly labeled and dated. Additionally, multiple frozen food packages had ice and frost buildup inside, indicating improper sealing. The dry storage area contained a plastic container and milk crates that were dirty, and a plastic tub of beef soup base was observed with black dust on the lid. The Food Service Director acknowledged that the cooks were responsible for labeling and dating food and ensuring packages were sealed to prevent freezer burn. Cold food items, including yogurt, milk, chicken salad sandwiches, and egg salad, were found to be stored at temperatures above the required 41 degrees Fahrenheit. The facility's policy required daily recording of food temperatures to ensure compliance with food safety standards, but the Cook's Temperature Log Sheet did not show evidence of monitoring cold food temperatures. Interviews revealed that staff did not routinely measure the temperature of cold food items such as sandwiches, milk, and yogurt, and the cooler used to keep cold items was broken and not replaced. The Administrator was unaware that the kitchen was not following the food storage and temperature procedures. The Food Service Director admitted that they did not routinely measure the temperature of cold food items served to residents. The failure to maintain proper food storage and temperature standards was a violation of the facility's policies and procedures, as well as state regulations.

Plan Of Correction

Plan of Correction: Approved March 3, 2025 Pine (NAME) Center For Rehabilitation and Healthcare provides the Following Plan of Correction 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice F812. The Food Service Director ensured that all improperly labeled and dated food items were discarded immediately. The Food Service Director gave in-services to the cooks on 2/4/2025 on properly labeling and dating food items. The Food Service Director cleaned the edge of the lid immediately upon recognition. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this alleged deficient practice. The Food Service Director did a kitchen-wide tour on 2/03/2025 to ensure that the facility is in compliance with food storage procedures. All negative findings were immediately corrected. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. The Administrator and Food Service Director reviewed the policy on Food Storage. No changes were made. They also reviewed the policy on Cleaning and Sanitation of Dining and Food Service Areas and the policy on Food Temperatures, and no changes were made. Kitchen staff were in-serviced on 2/04/2024 on the policies with specific focus on proper labeling of food packages, disposing of freezer-burned food, and on the cleanliness of the food storage areas. They were also in-serviced on Cold Food temperatures, with specific focus on keeping all cold food items on ice during preparation to adhere to the regulations. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility has implemented tray line temperature audits to ensure the facility is in cold food temperature compliance. Audits will be done weekly for the first 4 weeks and then monthly for the following 5 months. The facility has implemented audits on proper labeling/dating as well as cleanliness to ensure staff are adhering to state and federal regulations and will be done weekly for the first 4 weeks and then monthly for the following 5 months following. Audits will be discussed at the QA meeting to monitor for compliance. 5. The date for correction and the title of the person responsible for correction of each deficiency. The Administrator will be responsible for implementation and compliance by 03/10/2025.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have deficiencies in maintaining sanitary conditions in its kitchen, which serves food to residents. During a survey, it was observed that the compressor above the chest freezers was heavily dusted, and the mesh cover of the compressor in the walk-in refrigerator was dusty and in disrepair. Additionally, the compressor was leaking directly onto the floor of the walk-in refrigerator, where uncovered crates of milk cartons were stored directly underneath, and a puddle of standing water was present nearby. Further observations revealed that food debris was present on the floor under the racks storing food for resident consumption in the walk-in refrigerator. The Director of Food Services mentioned that the walk-in boxes are cleaned daily in the afternoon, but there were no cleaning logs to verify this, and the cleaning was part of the kitchen staff's job description. The Director of Maintenance acknowledged responsibility for the maintenance of the compressor fans and indicated plans to repair and clean them. The facility's policies and procedures, effective from October 2024, state that food should be stored in clean, dry areas free from contaminants and that refrigerated units should be kept clean and in good working condition. Additionally, a comprehensive cleaning schedule should be maintained, with tasks being initialed upon completion. However, the lack of adherence to these policies contributed to the observed deficiencies in food storage and equipment maintenance.

Plan Of Correction

Plan of Correction: Approved March 10, 2025 Pine (NAME) Center For Rehabilitation and Healthcare provides the following Plan Of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The food service director immediately moved the milk crates to a different location in the fridge. 4. The compressor above the chest freezer has been cleaned and will be checked weekly to ensure no dust build-up. 5. The walk-in fridge has been swept and cleaned. 6. The food service director inserviced all staff on filling out the cleaning logs. 7. The EVS Director reached out to the vendor who will be replacing the fan mesh cover and fixing the leak. The vendor came on site, and the facility received and approved the quote. The vendor will be onsite 3/12/2025 to complete the work. 8. The food service director will conduct daily checks of the walk-in fridge until it is repaired and report all findings to the administrator/EVS Director. 9. The food service director will conduct daily checks of the walk-in fridge to ensure it has been swept and cleaned. 10. The EVS Director/designee will present any findings at the quarterly QA/QAPI meetings. 11. The EVS Director/designee will be responsible to correct this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that live parts of electrical equipment were adequately guarded against accidental contact, as required by NFPA 70: National Electrical Code. During a Life Safety Code recertification survey, surveyors observed several deficiencies related to electrical installations. On the second floor, electrical cables were found hanging by the wall near a ramp in a resident-occupied area. In the basement's former rehabilitation room, live electrical cables were stored in a plastic bucket and left out in the open, and additional cables were seen hanging from the ceiling. These observations indicate a failure to maintain electrical installations in a neat and workmanlike manner, as well as a failure to guard live parts against accidental contact, posing potential safety hazards to residents and staff.

Plan Of Correction

Plan of Correction: Approved March 6, 2025 Pine(NAME) Center for Rehabilitation and Healthcare provides this Plan Of Correction. 1. No Residents were affected by this deficient practice. 2. All residents have the potential to be affected by this deficient practice. 3. The electrical cables by the ramp have been covered and the facility will have the vendor onsite to discuss removing the cables. 4. The cables in the former Rehabilitation room have all been removed or covered up. 5. The EVS Director/designee will conduct an audit around the facility to identify any additional wiring that needs to be covered up. 6. The EVS Director will audit the facility every week for the first 4 weeks and then monthly for 3 months and then quarterly for up to a year to ensure all live electrical cables are covered. 7. The EVS Director/designee will present any findings in the quarterly QA/QAPI meetings. 8. The EVS Director/designee will be responsible to correct this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its sprinkler system in accordance with NFPA 25 standards, as evidenced by the lack of testing or replacement of sprinkler system gauges within the required five-year interval. During the Life Safety Code recertification survey, it was noted that the gauges had not been replaced or tested since December 23, 2019, which exceeded the five-year requirement. Additionally, the facility did not provide documentation of an antifreeze test for the sprinkler system, which is required annually to ensure the correct freeze point of the antifreeze solution. Further investigation revealed that the antifreeze test conducted on February 29, 2024, indicated an incorrect freeze point in the emergency stairwell system, with a recommendation to drain and replenish the system. However, there was no evidence provided to confirm that corrective actions were taken following this recommendation. The facility's failure to maintain proper records and perform necessary maintenance actions led to the deficiency noted in the survey.

Plan Of Correction

Plan of Correction: Approved March 11, 2025 Pine (NAME) Center for Rehabilitation and Healthcare provides the following Plan of Correction: 1. No residents were affected by the deficient practice. 2. All residents have the potential to be affected by the deficient practice. 3. The facility has a signed quote for the gauge testing/replacement; the vendor will be onsite to perform the 5 year/gauge inspection/replacement. 4. The Administrator will coordinate with the EVS Director/vendor to conduct retesting of the emergency stairwell freeze point and drain and replenish if needed. 5. The vendor will be onsite 3/20/2025 to conduct all necessary testing/replacements. 6. The facility has created an alert in our maintenance portal to alert when the facility is due for testing. 7. The EVS Director/designee will coordinate with the vendor to schedule/conduct any further required testing. 8. The EVS Director/designee will call the vendor and have them come down to inspect the emergency stairwell system, and they will perform any necessary work and retest once the work is completed. 9. The EVS Director/designee will report any findings at the quarterly QA/QAPI meetings. 10. The EVS Director/designee are responsible to correct this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility was found to have deficiencies in maintaining a comfortable and sanitary environment for residents, as required by regulations. Observations revealed that in two of the four nurse units, there were issues such as peeling paint on corridor walls and around door frames, non-functional exhaust fans in a nurse station's toilet and a resident's room, and unsecured handrails by a ramp. Additionally, a resident's room on the first floor had peeling paint around the window frame and stained ceiling tiles. These deficiencies were noted during a survey conducted over two days, with the Director of Maintenance and the Administrator present during the observations. The Director of Maintenance stated that housekeeping staff clean residents' rooms, toilets, and floors daily, but these activities are not recorded. The Director also mentioned that daily walkthroughs are conducted to identify issues needing repair, such as peeling paint, and that environmental staff receive training every three months. Despite these measures, the facility acknowledged the findings and indicated plans to repaint and renovate the affected areas, although no definitive timeline was provided for these actions.

Plan Of Correction

Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Pine(NAME) Center For Rehabilitation and Healthcare provides the following Plan Of Correction. 1. No residents were affected by this deficient practice. 2. All Residents have the potential to be affected by this deficient practice. 3. The toilet in room [ROOM NUMBER] has been repaired by the maintenance team. 4. The maintenance team has started plastering/repainting/repairing the entire second floor. 5. The handrail by the ramp has been readjusted and tightened to ensure it is firmly secured. 6. Room [ROOM NUMBER] has been plastered and repainted, and stained ceiling tiles have been replaced. 7. An exhaust fan for the second floor bathroom was purchased and installed by the maintenance team. 8. The EVS Director inserviced all his staff on the facility's policy on high dusting. 9. Audits will be conducted every week for the first 4 weeks and monthly for the next 3 months to ensure high dusting is completed. 10. The EVS Director/designee will ensure any items put into the facility's maintenance system are immediately addressed. 11. The EVS Director will report any findings at the quarterly QA/QAPI Meetings. 12. The EVS Director will be responsible for the correction of this deficiency.