Pine Tree Lodge Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF697Mar 25, 2026

  Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 of 13 residents (Resident #49) reviewed for pain management. The facility failed to ensure Resident #49 received her scheduled pain medication (oxycodone) on the following dates and times:1. On 11/03/25, Resident #49 missed her 2 p.m. dose, which resulted in moderate 5 out of 10 pain on the 1-10 pain scale.2. On 11/13/25, Resident #49 missed her 10 p.m. dose, which resulted in severe 9 out of 10 pain on the 1-10 pain scale.3. […]

• Immediate jeopardy, patternF755Mar 25, 2026

  Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of all drugs and biologicals to meet the needs of each resident for 1 of 13 (Resident #49) residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #49 received her scheduled oxycodone (narcotic pain medication) on 10/21/25, 11/03/25, 11/13/25, 11/23/25, and 03/23/26. 2. The facility failed to ensure Resident #49's oxycodone was re-ordered timely to prevent missed doses on 11/03/25, 11/13/25, and 03/23/26. 3. The facility failed to ensure a system was in place for medication reconciliation of narcotic medications and count sheets. 4. […]

• Immediate jeopardy, patternF580Nov 6, 2023

  Based on interview, and record review the facility failed to immediately consult with the resident physician when there was significant change in the resident physical condition for 1 of 4 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced 35 elevated blood pressure readings in the month of [DATE] . The facility failed to notify the physician when Resident #1 had an unwitnessed fall on [DATE] at approximately 080:00, her BP reading was ,d+[DATE]. Resident #1 had a change in condition and was sent out to the hospital at approximately 10:45 a.m., her BP reading at that time was ,d+[DATE], she died at the hospital the following day. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:00 p.m. […]

• Immediate jeopardy, patternF760Nov 6, 2023

  Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1's physician ordered Clonidine for high blood pressure 35 times during the month of [DATE] that resulted in the death of Resident #1. An Immediate Jeopardu (IJ) situation was identified on [DATE] at 6:00 p.m. While the IJ was removed on [DATE] at 4:15 p.m., the facility remained out of compliance at actual harm with a scope of pattern due to the facilities need to evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, isolatedF755May 18, 2023

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administration of medications for 1 of 1 residents (Resident #1) reviewed for medication omission. 1. the facility failed to follow their protocol by failing to reorder a prescribed medication timely to prevent seizures, and Resident #1 missed two doses of medication, because his medication was not available and he had two back-to-back seizures and was taken to the hospital. (Clobazam (Onfi), used along with other medicines to treat seizures associated with Lennox-Gastaut syndrome, which is a severe condition characterized by repeated seizures (epilepsy) that begin early in life). 2. […]