Pine Lodge

In the surveyor’s words

From the most serious findings on record at Pine Lodge, in the surveyor’s own words.

• Immediate jeopardy, patternF880Mar 18, 2021

  Based on record review, observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents residing in the facility. The facility failed to provide Resident #87's [CONDITION(S)] care, gastroscopy tube care, and pressure ulcer care in a manner to prevent the spread of infection. […]

• Actual harm, isolatedF600May 21, 2026

  Based on record review and staff interview the facility failed to ensure Resident # 3 was free from neglect. Nurse Aide #137 was assigned to be on one to one supervision with Resident #3 due to multiple falls. NA #137 neglected the resident by leaving the residents room braking the one to one supervision to go to the nurses station to plug up his phone. While he was out of the room Resident #3 got out of bed and fell and sustained a fracture to her facial bones. The neglect perpetrated by Resident #137 resulted in actual harm for Resident #3 when she sustained a [NAME] Fort 1 fracture (A horizontal fracture separating the teeth and hard palate from the upper maxilla. The upper teeth are mobile, but the nose and eyes remain stable). […]

• Actual harm, isolatedF600Jan 5, 2022

  Based on observation and staff interview, the facility failed to ensure residents were free from verbal and emotional abuse. The surveyor was witness to the verbal and emotional abuse of Resident #71 in the public hallway by the nurses station. The Nurse Practitioner verbally berated Resident #71 on two (2) occasions. She was removed from the situation and then returned to continue the verbal assault of Resident #71 for a second time. This cause psychosocial harm to Resident #71. Resident #54 was also verbally abused by a nurse at the facility on the same day. Resident #54 did not appear to suffer any harm from this. but the potential existed for him to suffer psychological harm. These were random opportunities for discovery. Identified Residents #71, and #54. […]

• No harm, potential for more than minimal, widespreadF725Nov 15, 2023

  Based on record review, resident interviews, staff interviews and observations, the facility failed to ensure all staff were competent and there were Sufficient nursing staff relate: to extremely late and omitted medications, Nursing staff failed to notify the physician and/or not done timely when blood glucose levels are not in the set parameter, showers not provided for dependent residents, missed treatment, lacking in meaningful activities, catheter care, care for tube feedings, staff adhering to infection control practices (including residents that are positive for COVID-19), and staff failed to document and dispense night time ordered snacks. […]

• No harm, potential for more than minimal, widespreadF732Nov 15, 2023

  Based on observation, facility document review, and staff interview the facility failed to post a staff posting that included the census, total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care. This was true for the last quarter and currently. These failed practices had the potential to affect all residents. Facility census 117. Findings included: a) Staff postings On 11/12/23 at 10:30 AM it was noted the staff posting located at the front lobby of the facility did not contain the information of a daily census, number of nurse aides, number of nurses, and the total hours worked per day. […]