Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Tree Lodge Nursing Center during CMS and state inspections, most recent first.
Failure to Provide Privacy During Incontinent Care: A resident with diabetes, recurrent depressive disorders, stroke, and moderate cognitive impairment was observed receiving incontinent care without a middle curtain in place, allowing her roommate and the surveyor to see her. The resident said she was embarrassed and wished there was a curtain. CNA B said no curtain was available, and the DON and Administrator stated privacy should have been provided during personal care.
Failure to Provide and Document Scheduled Bathing: A resident with stroke-related ADL dependence and aphasia did not have baths documented on multiple scheduled bathing days. Family members said the resident was not being kept clean, and staff confirmed baths should have been provided and documented, but there was no record of refusals in the progress notes.
A resident with chronic pain and opioid dependence missed scheduled oxycodone-acetaminophen doses when the medication was unavailable or had not yet arrived from the pharmacy. Staff substituted other pain medication on one occasion, but another missed dose had no replacement documented, and the resident reported severe uncontrolled pain, including 10/10 pain during observation. Interviews showed nurses were responsible for re-ordering narcotics, and staff acknowledged the resident had run out of pain medication more than once.
A resident with chronic pain and opioid dependence experienced repeated missed doses of scheduled oxycodone and Tylenol #4 because narcotic meds were not reordered timely and MAR entries did not match the controlled-drug count sheets. The DON stated there was no system for reviewing the count sheets, and staff interviews showed the resident’s pain meds frequently ran low before pharmacy delivery, leaving the resident in severe pain when doses were unavailable.
An LPN failed to perform hand hygiene before and after medication administration, before and after a fingerstick blood sugar check, and before and after insulin administration for two residents. The LPN also did not sanitize the glucometer or clean the insulin vial stopper before drawing up insulin. The DON and Administrator stated these infection control practices were expected during med pass.
A resident with an indwelling catheter and a physician order for a privacy bag had his Foley bag left visible from the room entrance and hallway without a privacy cover. Staff, including a CNA, the DON, and the Administrator, stated that CNAs and nurses were responsible for ensuring privacy covers were in place, and the resident said it bothered him that his urine was visible to anyone passing by.
Dim Room Lighting: A resident with severe cognitive impairment, total ADL dependence, incontinence, and a fall risk care plan had repeated unwitnessed falls in his room. Surveyors observed the main room light was not working or was very dim on multiple occasions, leaving the room very dark. Staff acknowledged the issue had been reported to nursing and maintenance, but the lighting remained inadequate during observations.
Failure to Assist Resident With Pure Wick Use: A resident with bladder incontinence and an order for a pure wick urine collection system did not receive consistent staff assistance with the device. The resident, family, LVN, ADON, DON, and Administrator gave conflicting accounts about whether staff knew how to use the system, whether it was allowed, and who was responsible for placing it. The resident stated she wanted to use the device because it was better than urinating on herself, but staff reported they had not been trained or were unsure how to use it, and the facility had no policy for the pure wick system.
PEG Feeding Not Administered for Ordered Hours: A resident with severe malnutrition, dysphagia, and a PEG tube had an order for Isosource 1.5 at 55 cc/hour for 22 hours daily, but surveyors observed the enteral pump inactive and beeping while connected to the resident, with little formula left in the bag. An LPN said the resident should be getting feeding all day and was changing the bag, while the ADON and DON confirmed the observed period was not scheduled downtime and the feeding should have been running.
Unclean Oxygen Concentrator Filters: Two residents receiving O2 via nasal cannula were observed with running concentrators that had gray fuzzy buildup on the filters. One resident had a TAR entry for filter cleaning on Sunday nights but no documentation that it was completed, while the other had no filter-cleaning order or documentation. Staff, including the DON and Administrator, stated night shift nurses were responsible for weekly filter cleaning, and facility policy referenced manufacturer instructions for cleaning concentrator filters.
Unsecured Medication Stored in Resident Room: A cognitively intact resident with hypothyroidism, hyperlipidemia, and bipolar disorder had two bottles of Nystatin Topical Powder in her room. She said she wanted to keep the powder there for self-use and that staff had not removed it or told her she could not keep it in the room. An LVN, DON, and Administrator stated that medications should be stored in the med/treatment cart and not left in resident rooms.
A resident with intact cognition, diabetes, chronic pulmonary edema, and major depressive disorder was found to have a broken call light that remained nonfunctional during repeated observations. Staff saw the broken call light but did not report it, and the resident said she had to yell for help when she needed assistance. Interviews showed the maintenance request was not entered until the Area Maintenance Supervisor demonstrated the process, and the facility lacked a functioning call light policy.
A facility failed to provide consistent dialysis care for a resident with end-stage renal disease by not completing post-dialysis assessments and not updating dialysis orders when the resident's schedule changed. The resident, with moderately impaired cognition, received hemodialysis twice a week, but the facility did not document post-dialysis assessments on multiple occasions. Interviews with staff revealed a lack of processes to ensure assessments were completed and orders updated, placing the resident at risk for complications.
The facility failed to maintain accurate records for controlled drugs, with numerous unlogged medications found in storage. Additionally, a resident with diabetes did not receive properly administered insulin, as the LVN did not prime the insulin pen before use. Both the DON and LVN were unaware of the necessary procedures, leading to potential medication errors.
The facility failed to act on pharmacy recommendations for gradual dose reductions (GDR) for three residents' medications, including risperidone, buspirone, and paroxetine. Documentation of pharmacy recommendations or rationale for GDR attempts was missing, and the Pharmacist Consultant was unaware of a resident's medication. Staff turnover and lack of consistent processes contributed to the deficiency.
A LTC facility failed to secure medications properly, leading to deficiencies in medication management. A resident with dementia had pills left unattended on her bedside table, and multiple medication carts were found unlocked and unattended by staff, allowing unauthorized access. These lapses violated the facility's policy on medication storage.
The facility failed to provide palatable and appropriately tempered food during a lunch meal, as reported by several residents and confirmed by state surveyors. Residents complained about excessive saltiness and cold temperatures of the food. The Dietary Manager, responsible for tasting and handling complaints, had not conducted a recent in-service on recipe adherence, and the facility lacked a specific policy on food palatability.
The facility failed to maintain food safety standards, with expired food items found in the refrigerator and unclean kitchen equipment, such as a can opener and microwave, observed during an inspection. The Dietary Manager admitted to oversight failures, and the Administrator was unaware of these issues prior to the survey.
A facility failed to coordinate assessments with the PASRR program for a resident with a mental illness diagnosis. The resident's PASRR Level 1 Screening form incorrectly indicated no evidence of mental illness, despite having a diagnosis of bipolar disorder and receiving antipsychotic medication. The MDS Coordinator missed the diagnosis, leading to the resident not receiving necessary PASRR services. The DON was unfamiliar with the PASRR process, and the Administrator expected adherence to PASRR policy and regulations.
A facility failed to implement a comprehensive care plan for a resident by not ensuring a fall mat was placed beside her bed as ordered. Despite the resident's severe cognitive impairment and fall risk, observations and staff interviews confirmed the absence of the fall mat, contrary to the care plan and physician's orders.
A resident with dementia and COPD was found with an unsecured oxygen cylinder in her room, despite not having orders for oxygen therapy. The cylinder was observed free-standing on the floor over multiple days, contrary to facility policy requiring secure storage. Staff interviews confirmed the risk of injury from the unsecured cylinder.
A resident with COPD did not have their nebulizer mask bagged or labeled when not in use, as observed during a survey. Staff interviews revealed a lack of awareness and training on proper nebulizer care. The DON and Administrator acknowledged the importance of bagging and labeling for infection control.
A long-term care facility failed to maintain an effective infection prevention and control program. A CNA did not change gloves during incontinent care, using the same gloves to handle clean linens that fell on the floor. An LVN did not wear a gown while administering medication through a gastrostomy tube to a resident under Enhanced Barrier Precautions. These actions were contrary to the facility's infection control policies, risking cross-contamination and infection spread.
A facility failed to offer a pneumococcal vaccination to a resident in accordance with CDC guidelines. The resident, who had severe cognitive impairment and a history of asthma, had previously received the Prevnar 13 vaccine but was not offered the subsequent PCV20 or PCV21 vaccine. The facility lacked a recent consent or declination form, and the comprehensive care plan did not address pneumonia vaccinations. Interviews with the Administrator and DON revealed lapses in following vaccination policies.
The facility failed to provide contracture prevention devices for two residents with right-hand contractures. One resident with quadriplegia did not have a splint as required by his care plan, and staff were unaware of the need. Another resident with Alzheimer's had a physician's order for a soft/rolled fabric, but it was not consistently applied, and staff were unaware of the requirement. The facility's policy on immobilization devices was not followed, leading to deficiencies.
The facility failed to follow professional standards for food service safety, with numerous food items in the kitchen refrigerator and freezers not labeled or dated, and some expired. Dietary staff admitted to not labeling or dating due to time constraints, and the Dietary Manager did not conduct a daily walk-through. The Administrator was unaware of these issues, despite the facility's policy requiring proper food storage practices.
A resident with quadriplegia reported that staff frequently turned off his call light without returning to assist him, leading to feelings of anger and disrespect. A CNA admitted to not returning to help the resident, citing difficulty in finding assistance. An LVN confirmed the incident, noting the resident's care was time-consuming. The facility's policy requires staff to keep call lights on until needs are met.
The facility failed to provide scheduled bathing services for three residents, leading to missed showers and inadequate personal hygiene care. Despite being scheduled for regular baths or showers, documentation showed multiple instances where these services were not provided. Interviews with staff revealed issues with documentation and adherence to the facility's bathing policy, impacting the residents' hygiene and dignity.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
The facility failed to treat a resident with dignity and respect and to provide privacy during incontinent care. Resident #1 was a female admitted with diagnoses including diabetes, recurrent depressive disorders, and stroke. Her annual MDS indicated a BIMS of 08, showing moderate impaired cognition, and she was dependent on staff for toileting hygiene. Her care plan stated that she was incontinent of bowel and bladder and required checks and assistance with toileting as needed per facility protocols and procedures. During an observation, Resident #1 was receiving incontinent care from CNA B in a room without a middle curtain, allowing the resident to be seen by her roommate and the surveyor. The resident stated she wished there was a curtain and said she was embarrassed and very bothered by being seen during the change. CNA B acknowledged there was no curtain and said she could not pull one because none was present. The DON and Administrator both stated they expected privacy to be provided, including using blankets or obtaining help to create privacy, and noted that staff should always provide privacy for residents.
Failure to Provide and Document Scheduled Bathing
Penalty
Summary
The facility failed to provide the necessary services to maintain personal hygiene for a resident with recurrent depressive disorders, stroke, and aphasia following stroke. The resident’s annual MDS indicated a BIMS of 99 and that she required maximal assistance to total dependence for ADLs. Her care plan identified an ADL self-care performance deficit related to stroke and limited range of motion on the right side, with interventions for assistance with personal hygiene as needed and bathing with 1 staff member. Record review of ADL task documentation showed no baths documented for three scheduled bathing days, and the progress notes did not indicate that the resident refused bathing or showering. Family members stated they felt the resident was not being kept clean and reported that she had only had one bath since the first of the year. A CNA stated the resident was bathed on Mondays, Wednesdays, and Fridays and that baths should be documented, but she did not know why the resident missed the documented bathing days. The DON and Administrator stated that CNAs, charge nurses, and management were responsible for ensuring scheduled baths occurred and were documented, and that refusals should be charted in the progress notes.
Missed Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident with chronic pain, opioid dependence with withdrawal, and morbid obesity who had a BIMS score of 14 and was able to clearly communicate her pain. Resident #49 had a comprehensive care plan identifying a potential for uncontrolled pain, with a goal of pain level 0 and interventions to anticipate pain relief, respond immediately to complaints of pain, evaluate effectiveness of pain interventions, and monitor for side effects and non-verbal signs of pain. Her physician order was for oxycodone-acetaminophen 10-325 mg three times daily for moderate to severe pain. Record review showed multiple missed scheduled doses of oxycodone-acetaminophen. On 11/03/25, the 2 p.m. dose was not given because medication was unavailable, and tramadol was given instead; the resident’s pain level was documented as 5/10. On 11/13/25, the 10 p.m. dose was not given because the medication was unavailable, and there was no evidence of another pain medication being given at that time; the next documented pain assessment on 11/14/25 at 6 a.m. showed pain at 9/10. On 03/23/26, the 6 a.m. dose was missed because the medication had not yet arrived from the pharmacy, and the resident received acetaminophen-codeine 300-60 mg instead; the MAR documented the missed dose and the resident’s pain level at 5/10. During interview and observation on 03/23/26, Resident #49 stated she had not received scheduled pain medications on several occasions since admission, that she depended on the medication to keep her pain controlled, and that she was waiting for her 2 p.m. dose while in severe pain rated 10/10. She reported the lower-dose medication given earlier had worn off and said her pain became worse whenever she missed scheduled doses. Staff interviews reflected that nurses were responsible for re-ordering narcotic pain medications, that the resident had run out of scheduled pain medication at least twice, and that medication delivery problems and late triplicate submission contributed to the missed doses. The DON stated severe or uncontrolled pain should have been reported to the doctor immediately, and the Medical Director stated he was unaware the resident had been in severe, uncontrolled pain.
Controlled Pain Medication Reconciliation and Timely Dispensing Failure
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and reconciliation of controlled medications for Resident #49, a female resident with morbid obesity, opioid dependence with withdrawal, and chronic pain. Her admission MDS reflected clear speech, no cognitive impairment, no behaviors or refusal of care, and use of opioid pain medication. Her care plan identified a potential for uncontrolled pain and included interventions to anticipate pain relief, evaluate effectiveness, and monitor for side effects and non-verbal signs of pain. Record review showed repeated problems with Resident #49’s scheduled oxycodone-acetaminophen and acetaminophen-codeine orders, MAR entries, and Individual Control Drug Record forms. The report documented missed or unavailable doses of oxycodone-acetaminophen on multiple occasions, including doses not given because medication was unavailable or not signed out as given. The report also documented that oxycodone-acetaminophen was not reordered in time on several occasions, resulting in missed doses when the resident’s supply ran out before the next delivery. In addition, the MAR and count sheets did not match on multiple dates, and the Individual Control Drug Record forms contained incorrect dates, duplicate sign-outs, marked-through entries without explanation, and pill counts that did not reconcile. The report also described discrepancies with acetaminophen-codeine count sheets, including incorrect dates, marked-through doses without explanation, duplicate sign-outs, and pills unaccounted for. Staff interviews reflected that nurses were responsible for re-ordering narcotic medications, but there was no reliable system for follow-up after ordering, and the DON stated there was no system in place for reviewing or monitoring the Individual Controlled Drug Record forms. During observation and interview, Resident #49 reported severe pain and stated she had not received scheduled pain medication on several occasions, that she depended on the medication to keep her pain controlled, and that missing doses caused her pain to worsen. Staff and the Medical Director acknowledged that the resident’s pain medication had run out and that severe or uncontrolled pain should have been reported.
Infection Control Lapses During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program during medication pass for 2 residents, including a resident with dementia, type 2 diabetes, morbid obesity, hypertension, liver disease, and multiple routine medications, and another resident with type 2 diabetes who received daily insulin. During an observation of morning medication administration, LVN C did not perform hand hygiene before or after giving medications to the resident with dementia. The same nurse also did not perform hand hygiene before or after checking the diabetic resident’s blood sugar and administering insulin. During the same observation, LVN C did not sanitize the glucometer before or after checking the diabetic resident’s blood sugar. She also did not sanitize the top of the insulin vial before drawing up 20 units of Novolin 70/30 for administration. The diabetic resident’s record showed the blood sugar was 148 and the insulin dose was given in the morning by LVN C. In interview, LVN C stated hand hygiene should have been performed before and after medication administration, before and after checking blood sugar, and before and after giving insulin. She also stated the glucometer should have been sanitized before and after use and the insulin vial should have been cleaned before drawing up insulin. The DON and Administrator stated they expected these infection control practices to be followed during medication administration, and the report notes the pharmacy consultant had not identified any issues during visits.
Catheter Bag Left Visible Without Privacy Cover
Penalty
Summary
The facility failed to ensure Resident #1 had the right to be treated with respect and dignity when his catheter bag was left without a privacy cover. Resident #1 was a male resident admitted with diagnoses including urinary tract infection, and his admission MDS indicated he usually understood others and made himself understood, with a BIMS score of 11 showing moderately impaired cognition. His care plan identified that he had an indwelling catheter, and a physician order directed staff to ensure the Foley bag was in a privacy bag while in bed or in a wheelchair. During observation and interview, Resident #1's catheter bag was seen attached to the side of his bed and visible from the entrance of the room, with urine observed inside the bag and no privacy cover in place. The resident stated that it bothered him that his urine was visible to anyone who walked by. A later observation again showed the catheter bag visible from the hallway without a privacy cover. CNA G stated that CNAs and nurses were responsible for ensuring privacy covers were on catheter bags, and the DON and Administrator both stated that nurses and CNAs were responsible for placing privacy covers on catheter bags. The facility policy titled Catheter Care did not include information regarding a privacy cover.
Dim Room Lighting
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #40 by not ensuring adequate lighting in the resident’s room. Resident #40 was a male admitted and readmitted to the facility with diagnoses including severe protein-calorie malnutrition, muscle wasting and atrophy, generalized muscle weakness, and other abnormalities of gait and mobility and coordination. The MDS assessment reflected unclear speech, severe cognitive impairment with a BIMS score of 4, total assistance with ADLs, and bowel and bladder incontinence. The care plan identified him as at risk for falls and included interventions such as a low bed, floor mat, and anticipating and meeting his needs. The record showed Resident #40 had three unwitnessed falls in his room, with no injuries sustained. During multiple observations, the main light in his room was not working or was very dim, and the room was described as very dark. The resident stated he did not like the room being that dark. Staff interviews confirmed the dim light had been noticed and reported to nursing and maintenance, that bulbs had been ordered but had not yet arrived, and that the light remained dim during the survey observations. The Maintenance Supervisor stated he had been notified the day before and had another priority issue to fix before addressing the light in Resident #40’s room.
Failure to Assist Resident With Pure Wick Use
Penalty
Summary
The facility failed to ensure a resident with urinary incontinence received appropriate treatment and services to prevent UTIs when staff did not assist her with use of her pure wick urine collection system. Resident #30 was a 65-year-old female with diagnoses including morbid obesity with alveolar hypoventilation, hemiplegia and hemiparesis following cerebral infarction affecting her left non-dominate side, and unspecified fall. Her MDS indicated she had clear speech, understood and was understood by others, had a BIMS score of 14, required maximal assistance with toileting hygiene and personal hygiene, and was always incontinent of bladder and continent of bowel. The care plan dated 3/6/26 identified an ADL self-care performance deficit with interventions including staff assistance for toilet use. A revised care plan dated 3/24/26 added that Resident #30 had bladder incontinence and used the pure wick system for elimination, with nursing to monitor at least every 2 hours to ensure the system was working and that the resident did not need to be cleansed and changed due to leakage, and to empty the canister as needed. The order summary also indicated she may use the pure wick system with a start date of 3/24/26. During observation, the resident was in bed with the pure wick system on top of a portable tote in her room. The resident stated staff did not know how to use it and did not try to use it per her and family request. The family member stated she had to hook up the system herself and reported staff were unsure whether the resident could use it in the facility. The resident later stated someone who was not a facility employee set up the system and that she wanted to use it because it was better than urinating on herself. An LVN stated staff did not use those in the facility, did not know how to use it, and was not aware of the order. The ADON stated CNAs and nurses helped the resident use the system, while the DON stated the family provided supplies and instructed staff where to place it; the Administrator stated the facility was trying to get a policy for the pure wick system and that the resident was responsible for placing or assisting with placement.
PEG Feeding Not Administered for Ordered Hours
Penalty
Summary
Resident #40, a male with diagnoses including severe protein-calorie malnutrition, gastrostomy, and dysphagia, was assessed as having severe cognitive impairment, unclear speech, total dependence for ADLs, and bowel and bladder incontinence. His care plan identified that he required tube feeding and water flushes because of swallowing problems, and his physician’s order specified Isosource 1.5 calorie at 55 cc/hour via PEG tube for 22 hours each shift. During observation, Resident #40 was found in bed with the PEG tube connected to the enteral feeding bag and pump, but the pump displayed a message that it was inactive and had been idle for 10 minutes. The pump was beeping, and there was only a small amount of liquid in the feeding bag. A later observation showed the same condition, with the pump still inactive and beeping while connected to the resident. An LVN stated the resident should be getting his feeding all day and said she was changing the feeding bag at that time, noting she had last checked it around noon. The ADON stated the resident was on 22 hours of PEG feeding daily with 2 hours of downtime for therapy, showers, and gut rest, and said the feeding should have been running during the observed period. The DON stated the resident had downtime, but the period from 11:19 A.M. to 2:03 P.M. was not scheduled downtime and the feeding should have been running. The Administrator stated the feeding was expected to be administered for the number of hours ordered, and the facility policy stated nursing services were responsible for tube feeding administration and correcting problems with tube feeding.
Unclean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 of 18 residents reviewed for respiratory care. Resident #22 had diagnoses including dementia, COPD, and acute and chronic respiratory failure, and Resident #55 had diagnoses including dementia, chronic respiratory failure with hypoxia, and diabetes. Both residents were receiving oxygen therapy through a nasal cannula connected to a running oxygen concentrator. Record review showed no order for cleaning the oxygen concentrator filter for either resident. For Resident #22, the treatment record included an order to change or clean the filter of the nebulizer machine as needed on Sunday night, but there was no documentation that the filter had been changed or cleaned from 03/01/26 through 03/25/26. For Resident #55, the treatment record did not indicate an order to change or clean the oxygen concentrator filter, and there was no documentation that the filter had been changed or cleaned from 03/01/26 through 03/25/26. During multiple observations, both residents were seen with oxygen concentrators in use and gray fuzzy substance on the filters. Resident #22 was observed on 03/23/26, 03/24/26, and 03/25/26 with the gray fuzzy substance on the concentrator filter. Resident #55 was observed on 03/23/26, 03/24/26, and 03/25/26 with the same condition. Staff interviews indicated night shift nurses were responsible for cleaning the filters on Sunday nights, and the DON and Administrator stated they would have expected the filters for both residents to have been cleaned on 03/22/26. The facility policy stated oxygen concentrator filters should be changed or cleaned according to manufacturer instructions, and the Mayo Clinic handbook stated the filter/intake should be cleaned or vacuumed once a week.
Unsecured Medication Stored in Resident Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for 1 resident reviewed for drug storage. Resident #54, a cognitively intact female with diagnoses including hypothyroidism, hyperlipidemia, and bipolar disorder, had two bottles of Nystatin Topical Powder in her room during an observation on 3/23/26 at 9:35 a.m. She was not in the room at that time. During a later observation and interview on 3/23/26 at 3:00 p.m., Resident #54 again had two bottles of Nystatin Topical Powder in her room and stated that she wanted to keep the powder in her room so she could use it herself. She said staff had not taken it from her or told her she could not have it in the room. An LVN stated that residents are not allowed to keep any medications in their rooms, including nystatin topical powder, and that staff are responsible for ensuring medications are not left in residents' rooms and are stored properly. The DON and Administrator also stated that medications should be kept in the medication or treatment cart when not being used by staff.
Nonfunctioning Resident Call Light
Penalty
Summary
The facility failed to ensure Resident #5 had a functioning call light. Resident #5’s record showed diagnoses including diabetes, chronic pulmonary edema, and major depressive disorder. The annual MDS indicated the resident was understood and understood others, had a BIMS score of 15, required moderate assistance with toileting, and supervision with other ADLs. The care plan noted bowel and bladder incontinence, an intervention to assist with toileting as needed, and that the resident required assistance from one staff member for most ADLs. During observations, Resident #5’s call light was repeatedly found plugged into the outlet but broken away from the plug, leaving it nonfunctional. On one occasion, LVN A was in the room and said she could not fix the call light. Later observations on multiple occasions showed the same condition while the resident was in bed, awake or asleep. During an interview, Resident #5 said she did not know how long the call light had been broken and stated that when she needed help, she just yelled until someone came to her room. Staff interviews showed the broken call light had not been reported when first noticed. LVN A said she remembered finding the call light broken but did not report it and did not know the process for reporting maintenance issues. CNA B said he had been in the room several times and had not noticed the broken call light. The Area Maintenance Supervisor said no maintenance request had been entered until he demonstrated how to submit one, and the DON and Administrator stated staff were expected to report nonfunctioning call lights. The Regional Compliance Nurse stated the facility did not have a functioning call light policy.
Inadequate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide consistent dialysis services in accordance with professional standards for a resident with end-stage renal disease. The resident, a female with moderately impaired cognition, was receiving hemodialysis twice a week. However, the facility did not complete the post-dialysis assessments on multiple occasions, as required by their policy. This lack of documentation was noted on several dates, indicating a pattern of non-compliance with the facility's procedures for monitoring the resident's condition after dialysis. Additionally, there was a failure to update the resident's dialysis orders when her dialysis schedule changed. The resident's dialysis days were altered, but the order summary report did not reflect these changes, leading to discrepancies in the resident's care plan. Interviews with the nursing staff and the Director of Nursing (DON) revealed that there was no process in place to ensure that post-dialysis assessments were consistently completed, and the orders were updated as needed. The nursing staff, including an LVN and the DON, acknowledged the importance of completing post-dialysis assessments to monitor the resident's condition and ensure continuity of care. The Administrator also emphasized the need for accurate documentation and order updates to comply with regulations and prevent the resident from missing dialysis treatments. Despite these acknowledgments, the facility's failure to adhere to its policies placed the resident at risk for complications associated with inadequate dialysis care.
Failure in Medication Management and Insulin Administration
Penalty
Summary
The facility failed to maintain an accurate system for the receipt and disposition of controlled drugs, which was evident in the unlogged medications found in the controlled medications storage area. During an observation and interview, it was revealed that numerous medications, including Tylenol/Codeine, Hydrocodone, and Morphine Sulfate, were not logged on the drug destruction sheet. The Director of Nursing (DON) admitted to not having logged these medications due to time constraints and acknowledged that the medication log was not up to date. The last drug destruction was completed several months prior, and the DON was unsure about the destruction policy, indicating a lack of adherence to the facility's procedures. Additionally, the facility failed to ensure proper administration of insulin for a resident with diabetes. The Licensed Vocational Nurse (LVN) responsible for administering insulin to the resident did not prime the insulin pen before use, which is a necessary step to ensure the pen is functioning correctly and delivering the accurate dose. The LVN admitted to not being aware of the need to prime the insulin pen, and the DON also expressed a lack of awareness regarding this requirement. This oversight could potentially lead to incorrect insulin dosing, affecting the resident's blood sugar levels. The facility's policies on drug destruction and insulin pen use were not followed, as evidenced by the unlogged medications and improper insulin administration. The Administrator and the DON both acknowledged the importance of following these procedures to prevent medication errors and ensure resident safety. The failure to adhere to these policies could result in medications being lost, not destroyed properly, or residents not receiving the correct therapeutic benefits.
Failure to Implement and Document Pharmacy Recommendations for Gradual Dose Reductions
Penalty
Summary
The facility failed to act upon the recommendations of the pharmacist report of irregularities for three residents reviewed for Drug Regimen Review (DRR). Specifically, the facility did not provide documentation of the pharmacy recommendation or rationale for an attempted gradual dose reduction (GDR) for Resident #17's risperidone, Resident #52's buspirone, and Resident #56's paroxetine. Additionally, the facility did not ensure the Pharmacist Consultant addressed Resident #56's buspirone for a GDR. Resident #17, a female with a diagnosis of bipolar disorder, was taking risperidone, an antipsychotic medication. The pharmacy GDR recommendation for her antipsychotic medication could not be located in the pharmacy recommendations or her electronic medical records. Resident #52, a female with unspecified dementia, was taking buspirone, an antianxiety medication. Similarly, the pharmacy GDR recommendation for her medication was missing from the records. Resident #56, a female with dementia, anxiety, and depression, was taking both buspirone and paroxetine. The pharmacy GDR recommendation for her paroxetine was not found in the records, and the Pharmacist Consultant was unaware that she was taking buspirone. Interviews with facility staff revealed issues with the implementation and documentation of pharmacy recommendations. The Pharmacy Consultant noted that the facility had experienced staff turnover, which affected the implementation and monitoring of pharmacy recommendations. The Medical Director stated that he expected facility staff to ensure pharmacy recommendations were included in the medical record. The Director of Nursing (DON) described a process for handling pharmacy recommendations, but acknowledged that the lack of completion of GDRs could result in residents receiving unnecessary medications. The Administrator emphasized the importance of reviewing medications monthly and ensuring pharmacy recommendations were followed, but noted that the facility did not have an Assistant Director of Nursing (ADON) at the time.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were only accessible by authorized personnel, leading to several deficiencies in medication management. One incident involved a resident who had three unidentified pills left unattended on her bedside table. The resident, who had a history of dementia, bipolar disorder, schizophrenia, and high blood pressure, stated that she refused to take the medications given to her by a nurse the previous night. The nurse responsible for administering the medication did not ensure the resident took her medication before leaving the room, which was confirmed by another nurse who identified one of the pills as Mirtazapine. Additionally, the facility did not secure medication carts properly, as observed in multiple instances. On one occasion, an LVN left a medication cart unlocked and unattended in a hallway, allowing unauthorized personnel to access it. Another LVN was found to have left a medication cart unlocked twice, once after giving keys to a corporate staff member and another time after handling discontinued narcotic medication. These lapses in securing medication carts were observed by surveyors and acknowledged by the staff involved. Furthermore, the treatment cart was left unlocked and unattended by a treatment nurse who had just started working at the facility. The nurse admitted to not having a key to the cart until that morning and acknowledged the importance of keeping the cart locked to prevent unauthorized access. The facility's policy on medication storage, which requires medication rooms, carts, and supplies to be locked and attended by authorized personnel, was not adhered to, leading to potential risks of medication misuse or harm.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for one of the three meals reviewed. During the lunch meal on January 14, 2025, residents reported issues with the food, including excessive saltiness and cold temperatures. Specifically, one resident stated the food was too salty, another mentioned the food was not good, and a third resident noted the food was cold. On the following day, another resident reiterated that the food was not warm when received, and one resident found the spinach too salty. These observations were corroborated by four state surveyors who found the beef steak and spinach to be too salty, although the mashed potatoes, cheesecake, and dinner roll were deemed satisfactory. The Dietary Manager, who has been in her role for five years, stated that she regularly tastes the food before serving and handles all food complaints. She mentioned that staff had been in-serviced on following the recipe book, but the last in-service was conducted in July 2024. The Administrator, employed since July 2024, confirmed that she oversees the Dietary Manager and conducts test tray assessments quarterly. She acknowledged past complaints about the food and stated that the facility follows the recipe book for palatability, although there is no specific policy on it. The lack of a recent in-service and the absence of a palatability policy may have contributed to the issues observed during the survey.
Deficiencies in Food Safety and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the improper storage, preparation, and cleanliness of food and kitchen equipment. During an inspection, expired food items, such as a container of carrots, were found in the refrigerator, and the facility did not dispose of them as required. Additionally, the kitchen's dry storage area contained an unclean bread crumb container, and the can opener, utensil drawer, and microwave were observed to have food debris, indicating a lack of proper cleaning protocols. Interviews with the Dietary Manager revealed a lack of awareness and adherence to the facility's policies regarding food labeling, dating, and disposal. The Dietary Manager admitted to oversight failures, such as not discarding expired foods and not ensuring the kitchen was cleaned daily. The Administrator, who oversees the Dietary Manager, was unaware of these deficiencies prior to the survey and emphasized the importance of following dietary policies to prevent negative outcomes for residents. The facility's Dietary Services Policy & Procedure Manual outlines the necessity of marking expiration dates and discarding expired items, which was not followed in this instance.
Failure to Coordinate PASRR Assessments for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program under Medicaid, specifically for a resident with a mental illness diagnosis. The deficiency involved not submitting the correct PASRR Level 1 Screening to the local authority for a resident who had a diagnosis of bipolar disorder upon admission. This oversight was identified during interviews and record reviews, where it was found that the resident's PASRR Level 1 Screening form incorrectly indicated no evidence of mental illness, despite the resident having an active diagnosis of bipolar disorder and receiving antipsychotic medication. The MDS Coordinator acknowledged missing the resident's diagnosis of bipolar disorder, which resulted in the resident not having a positive PASRR Level 1 screening. This placed the resident at risk of not receiving necessary PASRR services. The Director of Nursing (DON) admitted unfamiliarity with the PASRR process, and the Administrator emphasized the expectation for the PASRR policy and regulations to be followed. The facility's policy required reviewing the PASRR Level 1 Screening form for completion and correctness prior to admission, which was not adhered to in this case.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the facility did not ensure that a fall mat was placed beside the resident's bed as stated in her care plan. This oversight was observed during multiple instances where the resident was found lying in bed without the fall mat, despite having a physician's order for it to be present every shift. The resident, who was severely cognitively impaired and at risk for falls, had a history of falls and required assistance with various activities of daily living. Interviews with staff, including a CNA, LVN, DON, and the Administrator, confirmed the absence of the fall mat and acknowledged the expectation that it should have been in place according to the care plan and physician's orders. The facility's policies on physician's orders and fall prevention strategies emphasized the importance of implementing individualized care plans to minimize fall risks. However, the failure to adhere to these policies and ensure the presence of the fall mat placed the resident at risk of not receiving appropriate interventions to meet her current needs.
Failure to Secure Oxygen Cylinder in Resident's Room
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards by not properly securing an oxygen cylinder in a resident's room. The resident, a female with a history of dementia, COPD, osteoporosis, and hallucinations, was observed with a free-standing portable oxygen cylinder on the floor next to her bed. Despite the resident stating she did not use oxygen, the cylinder remained unsecured over multiple observations. The facility's records did not indicate any orders for oxygen therapy for this resident, yet the comprehensive care plan included interventions for oxygen therapy. Interviews with staff, including an LVN and the DON, revealed that the oxygen cylinder should not have been free-standing and should have been secured in a rack, on the back of a wheelchair, or stored in the oxygen room. The staff acknowledged the risk of the cylinder falling and causing injury. The facility's policy on oxygen administration emphasized the need for securing portable oxygen cylinders, which was not adhered to in this instance, placing the resident at risk for injury.
Failure to Bag and Label Nebulizer Mask
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not ensuring that the resident's nebulizer mask was bagged when not in use. This deficiency was observed in a resident with chronic obstructive pulmonary disease (COPD) and other health conditions, who was prescribed a nebulizer treatment twice daily. During observations, the nebulizer mask and tubing were found in a drawer without a bag or label, contrary to professional standards of practice. Interviews with the resident and staff revealed that the nebulizer mask was not bagged after use, and staff were unaware of this oversight. The Licensed Vocational Nurse (LVN) responsible for bagging the masks was not aware of the issue and had not received recent in-service training on nebulizer care. The Director of Nursing (DON) and the Administrator also confirmed their lack of awareness regarding the improper storage and labeling of the nebulizer equipment. The facility's failure to bag and label the nebulizer mask and tubing was a breach of infection control protocols, as outlined in the facility's guidelines for nebulizer use. This oversight could potentially lead to respiratory complications for residents receiving respiratory care. The DON and Administrator acknowledged their responsibility for ensuring proper labeling and storage of nebulizer equipment, emphasizing the importance of these measures for infection control and resident safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. One significant issue involved a Certified Nursing Assistant (CNA) who did not change her gloves while providing incontinent care to a resident. The CNA used the same gloves throughout the process, including when handling clean linens, which fell to the floor and were subsequently applied to the resident. This action was contrary to infection control practices and placed the resident at risk for cross-contamination and infection. Another deficiency was observed with a Licensed Vocational Nurse (LVN) who failed to wear a gown while administering medication through a gastrostomy tube to a resident under Enhanced Barrier Precautions (EBP). Despite being aware of the EBP requirements, the LVN only wore gloves, believing that a gown was unnecessary for medication administration. This oversight was contrary to the facility's infection control policy, which required both gloves and gowns for high-contact activities, including enteral feeding care, to prevent infection. The facility's policies on infection control, hand hygiene, and the use of personal protective equipment (PPE) were not adhered to by the staff, as evidenced by the observations and interviews conducted during the survey. The Director of Nursing (DON) and the Administrator acknowledged the lapses in following infection control practices, emphasizing the importance of changing gloves between dirty and clean tasks and wearing appropriate PPE as per the EBP guidelines. These failures in infection control practices could potentially lead to the spread of infections among residents and staff.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that each resident was offered a pneumococcal immunization, as evidenced by the case of a resident who was not offered the vaccine in accordance with CDC guidelines. The resident, an elderly female with a diagnosis of asthma and severe cognitive impairment, had previously received the Prevnar 13 pneumococcal vaccination but was not offered the subsequent PCV20 or PCV21 vaccine as recommended. The facility's records did not include a recent consent or declination form for the pneumococcal vaccination, and the comprehensive care plan did not address pneumonia vaccinations. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that the facility did not have a recent pneumonia vaccination consent or declination form for the resident, and the pneumonia vaccination evaluation should have been completed annually. The Administrator, who was also the acting infection control preventionist, acknowledged the importance of offering pneumococcal vaccinations per CDC recommendations. The DON stated that pneumonia vaccinations should be reviewed twice a year and that consent or declination forms should be kept in the medical record. The facility's policy indicated that all residents should be offered the pneumonia immunization unless contraindicated, but this was not adhered to in the case of the resident in question.
Failure to Provide Contracture Prevention Devices for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease of range of motion (ROM) for two residents with right-hand contractures. Resident #1, a male with quadriplegia and a right-hand contracture, did not have a contracture prevention device in place. Despite his care plan indicating the need for a right-hand splint, no such device was observed during the survey. Interviews with staff revealed a lack of awareness and action regarding the resident's need for a splint or other device, and the Director of Nursing (DON) admitted to not having obtained an order for a contracture prevention device. Resident #2, a female with Alzheimer's disease and a right-hand contracture, also did not have a contracture prevention device in place. Her care plan did not address the need for such a device, although a physician's order was present for a soft/rolled fabric to be used daily. During the survey, it was noted that the resident had not received the device in about a month, and staff were unaware of the requirement. The DON acknowledged attempts to use a rag in the resident's hand but noted issues with compliance and discomfort. The facility's policy on immobilization devices was not followed, as evidenced by the lack of documentation and implementation of physician's orders for both residents. The Administrator confirmed that the expectation was for orders and policies to be followed to prevent worsening of contractures, but this was not done, leading to the identified deficiencies.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During a survey, it was noted that multiple food items in the kitchen refrigerator were not labeled or dated, including ready-made sandwiches, cups of tea and punch juice, and various juices and milk. Additionally, expired food items such as a large container of pineapple tidbits and prepared chili were found. The lack of labeling and dating extended to the kitchen freezers, where premade frozen pancakes and a bag of frozen chocolate chip cookies were not properly bagged, labeled, or dated. The dietary staff, including a long-term employee, admitted to not labeling or dating food items due to time constraints and reduced working hours. The staff member acknowledged that all food items should be labeled, dated, and sealed to prevent contamination and ensure resident safety. The Dietary Manager, responsible for overseeing the dietary staff, confirmed that labeling and dating were part of the facility's procedures, but could not recall when the last in-service training on these practices was conducted. The manager also admitted to not conducting a daily walk-through of the kitchen on the day of the survey due to being occupied with cooking duties. The facility's Administrator, who oversees the Dietary Manager, was unaware of the expired and improperly stored food items. The Administrator stated that daily walk-throughs of the kitchen were conducted but acknowledged the need for a checklist to ensure thorough inspections. The facility's dietary policy, dated 2012, outlines the requirements for food storage, including labeling, dating, and discarding expired items, but these procedures were not consistently followed, leading to the observed deficiencies.
Failure to Respond to Resident Call Light
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring staff responded appropriately to his call light requests. The resident, a male with quadriplegia, anxiety, and seizures, reported that staff frequently turned off his call light without returning to provide the necessary assistance. This issue was ongoing and had become routine since the beginning of the year. The resident expressed feelings of anger and disrespect due to the lack of timely assistance, which included needs such as being turned, receiving ice water, and having his colostomy bag changed. A specific incident involved a CNA who admitted to turning off the resident's call light and not returning to assist him before her shift ended. The CNA acknowledged the difficulty in finding help and did not inform the nurses of the need for assistance. An LVN confirmed the incident, noting that the resident was considered time-consuming to assist. The facility's administrator, who was not in position at the time of the incident, stated that staff are responsible for keeping call lights on until residents' needs are met, as per the facility's policy on resident rights.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for three residents who required assistance with activities of daily living (ADLs). Specifically, the facility did not ensure that these residents received their scheduled baths or showers, as documented in their care plans and ADL bathing reports. This deficiency was identified through observations, interviews, and record reviews, which revealed missing documentation for several scheduled bathing days for each resident. Resident #1, a male with quadriplegia and moderate cognitive impairment, was dependent on staff for bathing. His ADL bathing reports for May and June 2024 showed no documentation for multiple scheduled bath days, and he often received bed baths instead of showers. Similarly, Resident #2, who required supervision or touching assistance for bathing, also had missing documentation for several scheduled showers. Despite being on a night shift schedule initially, he requested a switch to day shift, hoping to receive his showers as scheduled, but still reported inconsistencies in receiving them. Resident #3, who was dependent on staff for bathing due to dementia and other conditions, also experienced missed scheduled showers. Interviews with staff, including CNAs and the DON, indicated that while showers and bed baths were scheduled three times a week, there were issues with documentation and staff availability. The facility's policy emphasized the importance of regular bathing for hygiene and skin integrity, yet the lack of adherence to this policy resulted in the identified deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 187 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Buckner Westminster Place | 3.4 mi | ★★★★★ | 0 | 0 |
| Heritage At Longview Healthcare Center | 3.8 mi | ★★★★★ | 1 | 0 |
| The Oaks At Longview | 3.8 mi | ★★★★★ | 8 | 0 |
| Avir At Longview | 4 mi | ★★★★★ | 8 | 0 |
| Longview Hill Nursing And Rehabilitation Center | 4.4 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pine Tree Lodge Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.