Pine Meadows Health Care

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF550Jul 8, 2026

  Based on facility policy review, observation, and interview, the facility failed to ensure residents were treated with dignity and respect when staff failed to provide personal care to 1 of 1 (Resident #1) sampled residents reviewed for Activities of Daily Living (ADL) care. The findings include: 1. Review of the facility policy titled, Promoting/Maintaining Resident Dignity, dated 10/26/2023, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.All staff members are involved in providing care to residents to promote and maintain resident… […]

• No harm, potential for more than minimal, isolatedF553Jul 8, 2026

  Based on facility policy review, medical record review, and interview, the facility failed to include the Resident and/or Resident Representative in the care plan conference for 2 of 20 (Resident #11 and Resident #64) sampled residents reviewed for care plan conferences. The findings include: 1. Review of the facility policy titled, Care Plan-Interdisciplinary Team, dated 9/28/2017, revealed .The resident, the resident's family and/or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. The care Plan will be printed and reviewed for accuracy prior to Care Conference. The care plan will be read aloud to the resident, family and IDT team. […]

• No harm, potential for more than minimal, isolatedF686Jul 8, 2026

  Based on facility policy review, medical record review, observation, and interview the facility failed to ensure wound assessments were completed accurately for 1 of 2 (Resident #95) sampled residents reviewed for pressure ulcers/wounds. The findings include: 1. Review of the facility policy titled, Pressure Injury Prevention Guidelines, dated 3/20/2024, revealed .To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence–based interventions for residents who are assessed at risk or who have a pressure injury present.Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment.staging,… […]

• No harm, potential for more than minimal, isolatedF880Jul 8, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the prevention and spread of infection when 1 of 1 staff (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) during medication administration through a percutaneous endoscopic gastrostomy (PEG) tube (tube inserted directly into the stomach to provide nutrition or medications) for 1 of 1 (Resident #86) sampled resident reviewed for PEG medication administration. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF550Jun 10, 2021

  Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect during dining when 2 of 28 staff members (Certified Nursing Assistant (CNA) #1 and Activities Assistant) stood to assist residents (Resident #65 and #37) with their meal. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/1/2021, revealed .the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life . Observation in the A Hall on 4/7/2021 at 1:01 PM, revealed CNA #1 was standing over Resident #65 to assist with the meal. […]