Green Pine Acres Nursing Home

In the surveyor’s words

From the most serious findings on record at Green Pine Acres Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Jan 28, 2026

  Based on observation, interview and document review the facility failed to ensure medications were secured for 2 of 2 residents (R2, R4) observed unattended on the Transitional Care Unit (TCU). In addition, the facility failed to ensure safe refrigeration temperatures were maintained for 1 of 4 medication refrigerators (TCU Fridge C) reviewed for medication storage. This had the potential to affect residents residing on the TCU. Findings include:Medication Left Unattended:R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses including heart disease and diabetes. R2 received daily injections of insulin. […]

• No harm, potential for more than minimal, patternF883Jul 26, 2023

  Based on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 5 of 5 residents (R26, R30, R32, R34, R38) reviewed for immunizations. Findings include: R26's Admission Record dated 7/26/23, identified an admitted [DATE], and was [AGE] years old. R26 had diagnoses that included Parkinson's disease and lewy body dementia. R26's Minnesota Immunization Information Connection (MIIC) dated 7/26/23, identified R26 received the pneumococcal polysaccharide vaccine (PPSV23) on 3/21/15, and pneumococcal conjugate vaccine (Prevnar 13) on 3/23/18. […]

• No harm, potential for more than minimal, isolatedF755Jan 28, 2026

  Based on observation, interview and document review, the facility failed to follow their policies, and or acceptable standards of practice, to ensure medication administration accuracy for 2 of 2 residents (R23, R66) reviewed for narcotic count accuracy. Findings include:R23's comprehensive Minimum Data Set (MDS) dated [DATE], identified R23 was cognitively aware and had diagnoses that included breast cancer, heart failure, and chronic obstructive pulmonary disease (COPD). R23 was receiving hospice services. R23's physician order dated 12/5/25, identified lorazepam oral tablet 0.5 milligram (mg). Give 1 tablet by mouth every 4 hours as needed for anxiety/agitation for 14 Days. […]

• No harm, potential for more than minimal, isolatedF641Mar 19, 2025

  Based on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect range of motion status for 2 of 17 residents (R2, R29) who were in the sample. Findings include: R2: R2's Physical Therapy Evaluation and Plan of Treatment dated 11/19/24, identified R2 impaired ROM in both upper and lower extremities. R2's admission Minimum Data Set (MDS) dated [DATE], R2's functional range of motion (ROM) identified R2 had no limitations of range of motion in either upper or lower extremities. Diagnoses included multiple sclerosis and quadriplegia. R2's Mobility Assessment-V2 dated 2/26/25, identified R2 had contractures present and was unable to extend his left elbow past 90 degrees. Bilateral knees and ankles had poor ROM. […]

• No harm, potential for more than minimal, isolatedF689Mar 19, 2025

  Based on observation, interview and document review, the facility failed to ensure the use of motion sensor pager devices were assessed for range upon implementation and when identified the sensor did not alert staff to movement as intended for 1 of 2 residents (R60) reviewed for falls. Findings include: The undated 433 CMU Manufacturer Instructions identified the range of the monitors were 150 to 300 feet; however, environmental factors such as concrete or brick walls and heavy electrical equipment could affect the range. The systems relied on technology which was subject to physical and environmental considerations transmitter would not be 100% accurate if it was out of range. It was the end users responsibility to make sure the product was used correctly and within range. […]