Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine View Center during CMS and state inspections, most recent first.
Food was served in an unsanitary condition during lunch observation when trays were reused without being sanitized between uses. Staff placed trash on the trays, dumped it into the trash can, and then reused the same trays to serve food. The Administrator verified that the trays were being reused without sanitization.
The facility failed to maintain an effective pest control program, as gnats were repeatedly observed in the bathrooms of three resident rooms, landing on toilet bases and seats, fixtures, and walls. A resident reported that the gnats had been present for months and believed a toilet leak around the base might be contributing. The infection preventionist acknowledged the presence of gnats in these bathrooms, and the administrator was aware of the issue but could not verify that the drains had been treated during the most recent pest control service.
Unsanitary bathroom conditions were observed in resident rooms 312 and 313, including missing caulking around sinks and toilets, stained tile, a yellow substance on a wall near a shower, and dirty buildup at wall bases. Two residents reported leaking toilets with water around the base, and an IP later acknowledged issues in the bathrooms of rooms 310, 312, and 313.
Incomplete Baseline Care Plan for ADL Assistance: A resident's baseline care plan contained blanks for the level of assistance needed with bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. The care plan identified the resident as needing assistance or being dependent for ADLs related to recent hospitalization, fatigue, and activity intolerance, but the MDS Coordinator acknowledged the required level of care was not specified.
Accident Hazards in Resident Areas: A resident sitting room had loose, crumbling sheetrock falling from the wall onto the floor in an area easily accessible to residents, and an LPN and the Administrator acknowledged the condition. In a separate hallway location, an inwall auxiliary heater was fully functional and became hot enough to burn flesh within 15 seconds, was about 2 feet from the floor, and was easily accessible to residents; the Unit Mgr and Sr Maintenance Director acknowledged the heater.
The facility failed to keep POST forms accurate for two hospice residents. For one resident, the POST form remained blank in the hospice section even after hospice services began and multiple care plan conferences were held; for another resident, the POST form was also not revised after hospice started and a care plan conference occurred. The DON acknowledged the hospice section should have listed the hospice agency’s name and phone number.
A resident's privacy was compromised during visitation due to another resident's disruptive behavior, including opening doors, cursing, and attempting to enter the room. Despite staff attempts to redirect the disruptive resident, the behavior persisted, affecting the resident's family visits. The facility administrator acknowledged the issue, confirming the lack of privacy provided.
The facility failed to promptly address grievances and keep residents informed of the progress toward resolution. One resident experienced ongoing disruptive behavior from another resident, with no grievance form completed or room change offered. Another resident filed a grievance against a staff member but received no response or written resolution. The facility did not adhere to its grievance policy, resulting in unresolved grievances and lack of communication.
The facility failed to store and label food according to professional standards, as observed in the kitchen's pantry and freezer. Unlabeled vanilla ice cream cups and cooked frozen sausage with inconsistent dates were found, confirmed by the Dietary Manager, indicating lapses in food storage practices.
A facility failed to issue a timely Notification of Medicare Non-Coverage (NOMNC) for a resident discharged home after Medicare Part A services ended. The resident, admitted with an altered mental state and weakness, met therapeutic goals for discharge. However, the NOMNC was not provided at least two days before service termination, as confirmed by the Business Office Manager.
A facility failed to provide a written Notice of Transfer/Discharge to a resident and the LTC Ombudsman during a hospitalization. A review showed no documentation of the notice, which should have included the reason for transfer, effective date, new location, and appeal rights. The Administrator confirmed the lack of evidence for these notifications.
The facility failed to provide written Bed Hold notices to two residents or their representatives during hospital transfers, as required. One resident was transferred to the hospital without evidence of a Bed Hold notice, confirmed by the Administrator. Another resident was discharged without documentation of a Bed Hold notice or contact with the resident or representative, confirmed by the DON.
The facility failed to update the PASARR for two residents with new mental health diagnoses. One resident had a Major Depression diagnosis, and another had a Bipolar Disorder diagnosis, but their PASARRs did not reflect these changes. The social worker confirmed the absence of updated PASARRs.
A facility failed to implement a person-centered care plan for a resident by not specifying her preferred bedtime. The resident expressed a desire to choose her bedtime, but the care plan included multiple options without indicating her actual preference. The Administrator confirmed the care plan was not person-centered.
A facility failed to contact a physician for a reassessment of a resident's capacity after a BIMS evaluation showed severe impairment. The resident, who had been hospitalized for a UTI and returned on hospice care, showed a significant decline in mental status. Despite this, the facility did not follow up with the physician, as confirmed by staff interviews.
The facility failed to follow physician orders for oxygen administration and monitoring for two residents. One resident was observed with an oxygen concentrator set below the prescribed level, and monitoring records were inconsistent and incomplete. An LPN confirmed the incorrect setting and adjusted it, but noted she was unfamiliar with the patients. Another resident also had incorrect oxygen settings and inconsistent monitoring, which was confirmed by another LPN and the administrator.
A facility failed to provide trauma-informed care for a resident with PTSD, stemming from a past traumatic event. The care plan inappropriately relied on the resident, who had severe cognitive impairment, to identify his own trauma triggers. The social worker was unaware of the resident's PTSD specifics and did not engage with the resident's family to gather necessary information, leading to inadequate care planning.
The facility did not complete and document annual performance reviews for all nurse aides, specifically affecting two employees. This oversight was confirmed by the Scheduling/payroll Manager and had the potential to impact the care of residents, given the facility's census.
The facility failed to ensure monthly drug regimen reviews were conducted by a licensed pharmacist for two residents. There was no evidence of completed reviews for specific months in the electronic medical records. The Administrator confirmed the lack of documentation for these reviews.
Unsanitary Reuse of Food Service Trays
Penalty
Summary
Food was served in an unsanitary condition during lunch observation. Trays were reused without being sanitized in between uses, and staff placed trash on the trays, dumped it into the trash can, and then reused the same trays to serve food. The Administrator confirmed in interview that the trays were being reused without sanitization.
Failure to Maintain Effective Pest Control in Resident Bathrooms
Penalty
Summary
The facility failed to ensure an effective pest control program was in place, as evidenced by the presence of gnats in multiple resident bathrooms. During a walkthrough on 04/20/26 at 11:00 AM, gnats were observed flying around and landing on the base and seat of the toilet, bathroom fixtures, and walls in the bathroom of Room #310, and the resident in that room acknowledged the gnats but could not recall how long they had been present. At approximately 11:20 AM the same day, similar observations of gnats flying and landing on the toilet base and seat, fixtures, and walls were made in the bathrooms of Rooms #312 and #313. The resident in Room #313 reported that gnats had been present in the bathroom for months and suggested a toilet leak around the base as a possible cause. On 04/21/26, the infection preventionist acknowledged the presence of gnats in the bathrooms of Rooms #310, #312, and #313 during a walkthrough and interview, and on 04/22/26 the administrator stated she was aware of the gnats in these rooms and could not verify that the drains had been treated during the last pest control service. These findings affected a limited number of residents in Rooms #310, #312, and #313 out of a facility census of 47 and were identified as a random opportunity for discovery during the survey. The deficiency centers on the ongoing presence of gnats in resident bathrooms and the lack of confirmation that appropriate pest control measures, such as drain treatment, had been implemented as part of the facility’s pest control program.
Unsanitary Bathroom Conditions in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms 312 and 313 and their bathrooms. During a facility walk-through, surveyors observed missing caulking around sinks and toilets, stained tile around toilet bases, a yellow substance on a wall next to a shower, and a buildup of a dirty substance in the far right corners at the base of the walls in the rooms and bathrooms. Resident interviews supported the observations. One resident reported that the toilet had been leaking around the base for over a month, and another resident reported water around the base of the toilet and stated it was leaking. An infection preventionist later acknowledged issues in the bathrooms of rooms 310, 312, and 313 during a walkthrough, and the administrator stated she had been made aware of the environmental issues in those resident rooms and bathrooms.
Incomplete Baseline Care Plan for ADL Assistance
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included the instructions needed to provide effective and person-centered care within 48 hours of admission. Resident #57 was admitted to the facility and later discharged on 12/01/25. Review of the electronic medical record showed the baseline care plan had been scanned into the record, but the care plan contained blanks in the sections for level of assistance needed for transfer, mobility, and activities of daily living. The first focus area on the baseline care plan stated that the resident required assistance or was dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, and toileting related to recent hospitalization resulting in fatigue and activity intolerance. The goal was that the resident's ADL care needs would be anticipated and met throughout the next review period. However, several interventions were left incomplete, including the level of assistance and number of staff needed for bed mobility, transfers, eating, toileting, dressing, personal hygiene, and bathing. During interview, the MDS Coordinator acknowledged that the baseline care plan had not specified the level of care needed for these areas.
Accident Hazards in Resident Areas
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible. During a walkthrough of the resident sitting room near the nurses' station, the surveyor observed loose, crumbling sheetrock pieces falling from the wall onto the floor under the left side of the window, in an area that was easily accessible to residents. An LPN acknowledged the crumbling sheetrock chunks and stated she had blocked off the area and would notify maintenance. The Administrator also acknowledged the falling sheetrock around the window and stated she had sent a message to maintenance. In a separate observation at the end of the 300 hallway, the surveyor found an inwall auxiliary heater that was fully functional and became hot enough to burn flesh within 15 seconds, located about 2 feet from the floor and easily accessible to residents moving through the hallway. The Unit Manager acknowledged the heater and stated she would contact maintenance, and the Senior Maintenance Director stated he must have overlooked it.
Incomplete POST Forms for Hospice Residents
Penalty
Summary
The facility failed to maintain accurate records for two hospice residents by leaving the hospice enrollment section blank on their POST forms. For Resident #44, the record showed a POST form dated 04/13/25 indicating no CPR if pulseless and not breathing, and selective treatment if pulseless and breathing. The form’s hospice section was left blank even though the resident began receiving hospice services on 05/06/25. The record also showed four care plan conferences after hospice services began, and the Director of Social Services acknowledged the hospice section should have been updated to reflect the hospice agency’s name and phone number. For Resident #6, the record showed hospice services began on 01/30/26, but the POST form was not revised and the section asking whether the patient was enrolled in hospice remained blank. The Social Services note reflected that a care plan was held on 02/11/26, and the Director of Social Services acknowledged there had been one care plan conference since hospice services began and that the hospice section should have been updated to reflect the hospice agency’s name and phone number.
Privacy Violation During Resident Visitation
Penalty
Summary
The facility failed to ensure privacy for a resident during visitation, as evidenced by repeated incidents involving another resident's disruptive behavior. The resident's Medical Power of Attorney reported that visitors, including herself, experienced issues with another resident who frequently opened the door, cursed at visitors, and attempted to enter the room. Despite these occurrences, no grievance form was filled out to document the issues. Progress notes revealed multiple instances where the disruptive resident opened the door, laughed, and left, or was found inside the room, refusing to comply with requests to leave or be redirected by staff. The disruptive resident exhibited verbally aggressive behavior towards staff and visitors, particularly when the resident's family members were present. This behavior included cursing, yelling, and physical aggression, such as attempting to kick and hit staff. The facility's staff attempted to redirect the disruptive resident, but he consistently refused to comply, necessitating intervention by multiple staff members to remove him from the area. The facility administrator acknowledged awareness of the complaint and confirmed that the resident and her visitors were not provided privacy during visitation.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances and keep residents informed of the progress toward resolution, as evidenced by the experiences of two residents. For one resident, multiple complaints were made regarding another resident's disruptive behavior, including entering the room uninvited, cursing, and being verbally aggressive. Despite these ongoing issues, no grievance form was completed, and the resident's family was not offered a room change until much later. The facility's policy required immediate action to prevent further violations and timely notification of resolution, which was not adhered to in this case. Another resident filed a verbal grievance against a staff member, but the facility did not provide any response regarding the status of the investigation. The resident's Medical Power of Attorney also expressed concern about the lack of communication from the facility. Although the facility conducted an investigation and concluded that the grievance could neither be substantiated nor refuted, they failed to notify the resident or provide a written resolution as required by their policy. The facility's grievance policy outlined specific steps for handling grievances, including documenting the grievance, taking immediate action, and notifying the person filing the grievance in a timely manner. However, in both cases, the facility did not follow these procedures, resulting in a failure to resolve grievances promptly and keep residents informed, as required by regulations.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service storage, as evidenced by observations in the kitchen's pantry and freezer. In the pantry area, small cups of what appeared to be vanilla ice cream were found unlabeled and without any dates. Additionally, in the freezer, cooked frozen sausage was discovered with a date labeled as 10/28/24, which was inconsistent with the use-by date of 04/22/24. These findings were confirmed by the Dietary Manager during the kitchen investigation, indicating a lapse in proper food labeling and storage practices.
Failure to Issue Timely NOMNC for Resident Discharge
Penalty
Summary
The facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely manner for a resident who was reviewed for beneficiary protection notification. The resident, who was discharged to home after the last covered day of Medicare Part A services, did not receive the NOMNC at least two calendar days before the end of the covered services, as required by the Form Instructions for the NOMNC CMS-10123. This oversight was confirmed during an interview with the Business Office Manager, who acknowledged that the NOMNC was not issued prior to the resident's discharge. The resident in question had been admitted to the facility with an altered mental state and overall weakness, with a care plan goal of returning to home/community living. The resident met the therapeutic goals established for discharge, as confirmed by the discharge summaries from physical, occupational, and speech therapy. Despite the resident's desire and readiness to return home, the facility's failure to provide the NOMNC in a timely manner meant the resident was not informed of their rights before the termination of Medicare Part A services.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to a resident and the long-term care Ombudsman during a hospitalization event. A medical record review revealed that a resident was transferred to the hospital, but there was no documentation indicating that the resident or their representative received a written notice detailing the reason for the transfer, the effective date, the new location, and the resident's appeal rights. Additionally, there was no evidence in the electronic medical record that the long-term care Ombudsman was notified of the transfer. During an interview, the Administrator confirmed that the facility could not produce evidence of the required notifications.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written Bed Hold notices to residents or their representatives during hospital transfers, as required. This deficiency was identified during the annual Long-Term Care Survey Process for two residents. Resident #27 was transferred to the hospital on May 17, 2024, but there was no evidence in the electronic medical record that a Bed Hold notice was provided. The facility's Administrator confirmed the absence of such documentation. Similarly, Resident #16 was discharged to a local hospital on October 20, 2024, without documentation of a Bed Hold notice being issued or any contact with the resident or their representative regarding the bed hold policy. The Director of Nursing confirmed the lack of documentation for Resident #16's transfer.
Failure to Update PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident or possible serious mental disorders. This deficiency was identified during the Long-Term Care Survey Process for two residents. Resident #6 was admitted with a diagnosis of Major Depression, effective from November 1, 2023, but the only PASARR on file was dated November 2, 2022, which did not reflect this diagnosis. The social worker confirmed that no updated PASARR was available to address the Major Depression diagnosis. Similarly, Resident #28 was admitted with a diagnosis of Bipolar Disorder, effective from September 26, 2024. The initial PASARR dated March 26, 2024, and a subsequent PASARR dated July 16, 2024, did not capture the Bipolar Disorder diagnosis. The social worker also confirmed the absence of a new PASARR reflecting this diagnosis. These findings indicate a failure to update the PASARRs to reflect significant changes in the residents' mental health conditions.
Failure to Implement Person-Centered Care Plan for Resident's Bedtime Preference
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #145, during the Long-Term Care Survey process. The deficiency was identified when the facility did not address the resident's preferred bedtime preference in her care plan. A record review revealed that the resident, who was admitted to the facility, expressed a preference to go to bed whenever she wanted, as noted in her Recreation Comprehensive Assessment dated 10/18/24. However, the comprehensive care plan created on 10/21/24 included an intervention that was not specific to the resident's preference, as it listed multiple options for bedtime without indicating the resident's actual choice. During an interview, the Administrator confirmed that the care plan was not person-centered, and it was unclear what the resident's bedtime preference was based on the intervention listed.
Failure to Reassess Resident's Capacity After Severe Impairment Noted
Penalty
Summary
The facility failed to contact the physician and request a reassessment of a resident's capacity after a Brief Interview for Mental Status (BIMS) evaluation revealed severe impairment. Resident #18, who had a history of severe impairment, was unable to recall when she entered the facility or how long she had been there during an interview. Despite this, the facility did not follow up with the physician for a reassessment of her capacity, even though a previous document from the resident's physician dated two months earlier stated that the resident had capacity. Further record review showed that Resident #18 had been admitted to the hospital for an acute urinary tract infection and was later discharged back to the facility on hospice care. A subsequent BIMS evaluation conducted by the social worker indicated a significant decline in the resident's mental status, with a score dropping from 12.0 to 5.0. Despite these findings, the facility did not take action to reassess the resident's capacity, as confirmed by interviews with the social worker and the facility administrator.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration and monitoring for two residents. Resident #5 was observed on oxygen therapy with the concentrator set at 2 liters per minute, contrary to the physician's order of 3 liters per minute via nasal cannula as needed. The monitoring records for Resident #5's oxygen saturation were inconsistent and incomplete, with no records available for specific dates during the survey period. LPN #29 confirmed the incorrect oxygen setting and adjusted it accordingly, but noted that she was not familiar with the patients as she was covering the hallway temporarily. Similarly, Resident #11 was observed receiving oxygen therapy with the concentrator set below the prescribed 3 liters per minute. The monitoring records for Resident #11 also showed inconsistencies, with no records available for several days during the survey. LPN #49 confirmed the incorrect setting and adjusted it to the correct dosage. The administrator acknowledged the lack of consistent monitoring for both residents, confirming that the facility did not follow the prescribed orders for oxygen therapy and monitoring.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The deficiency was identified during a review of the care provided to a resident who had a significant traumatic experience in his past, specifically related to a disaster at a power plant construction site. Despite the resident's severe cognitive impairment, the care plan inappropriately relied on the resident to identify his own trauma triggers, which was unrealistic given his condition. The care plan did not include input from the resident's family, who could have provided valuable insights into the resident's trauma history and potential triggers. The social worker at the facility admitted to not knowing the specifics of the resident's PTSD diagnosis or any potential triggers that could re-traumatize him. This lack of knowledge and failure to engage with the resident's family to gather necessary information resulted in inadequate care planning. The facility's oversight in not collaborating with the resident's family to identify and address trauma triggers contributed to the deficiency in providing culturally competent and trauma-informed care.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct and document a completed performance review for every nurse aide at least once every 12 months. This deficiency was identified through personnel file record reviews and staff interviews, specifically affecting employees #49 and #5. During an interview, the Scheduling/payroll Manager confirmed that the yearly performance reviews were not on file for these employees. This oversight had the potential to affect more than a limited number of residents, given the facility's census of 47.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review, including a review of the medical chart, for two of the five residents reviewed under the unnecessary medication's pathway. For Resident #27, there was no evidence in the electronic medical record that a medication regimen review was completed for the months of November 2023 and December 2023. Similarly, for Resident #28, there was no evidence of a completed medication regimen review for August 2024. During an interview, the Administrator confirmed the facility's inability to provide evidence that these reviews were conducted by the consulting pharmacist or reviewed by the attending physician.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Harrisville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belmont Healthcare Center | 16.4 mi | ★★★★★ | 10 | 0 |
| Minnie Hamilton Health Care | 20 mi | ★★★★★ | 23 | 0 |
| Elizabeth Care Center | 21.1 mi | ★★★★★ | 11 | 0 |
| Glenville Health & Rehab | 22.5 mi | ★★★★★ | 15 | 0 |
| Ohio Valley Health Care | 24.6 mi | ★★★★★ | 21 | 0 |
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