Pine Valley Center For Rehabilitation And Nursing

In the surveyor’s words

From the most serious findings on record at Pine Valley Center For Rehabilitation And Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Dec 22, 2025

  Based on observation and interview the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, twenty-five (25) food items were not properly identified and dated in the kitchen refrigerators, freezers, and food storage areas.Findings include:The facility policy titled Food Storage last revised May 2025, documented all containers must be legible and accurately labeled and dated. Food must be dated as it is placed on the shelves and left over food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before it is refrigerated. All foods should be covered, labeled and dated. […]

• No harm, potential for more than minimal, patternF686Dec 22, 2025

  Based on observation, record review, and interview the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent and/or treat pressure ulcers for three (3) of eight (8) residents (Residents #59, #91 and #100) reviewed for Pressure Ulcers. Specifically, 1) heel offloading was not implemented as per physician order for Resident #59 who was assessed at risk for pressure ulcers 2) heel offloading was not implemented as per comprehensive care plan and physician order for Resident #91 who was assessed at risk for pressure ulcers and 3) heel offloading was not implemented as per physician order for Resident #100 who was assessed at risk for pressure ulcers.The findings include:A policy titled Pressure Ulcer Prevention and Intervention… […]

• No harm, potential for more than minimal, patternF688Dec 22, 2025

  Based on observation, interview, and record review the facility did not ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for four (4) of six (6) residents (Residents #50, #34, #59, and #91) reviewed for Positioning and Mobility. Specifically, 1) the use of carrot splints was not implemented as per physician order and care plan for Resident #50 with contractures (fingers bent into the palms) of both hands, 2) the use of a left- hand roll brace was not implemented as per physician order for Resident #34, and 3) the use of a right resting hand splint was not implemented as per physician order for Resident #59. […]

• No harm, potential for more than minimal, isolatedF638Dec 22, 2025

  Based on interviews and record review the facility did not ensure the residents' Minimum Data Set assessments were completed not less frequently than once every three (3) months for one (1) of two (2) residents (Resident #44) reviewed for Resident Assessment. Specifically, a quarterly Minimum Data Set assessment was not completed three (3) months after the completion of the 06/28/2025 annual Minimum Data Set for Resident #44.The findings includeAn undated facility policy titled Comprehensive Assessment documented the Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments at least quarterly.Resident #44's diagnoses included obstructive uropathy, unstageable pressure ulcer of sacral region and adult failure to thrive. […]

• No harm, potential for more than minimal, isolatedF641Dec 22, 2025

  Based on record review and interview conducted during the recertification survey from 12/15/2025 to 12/22/2024, the facility did not ensure that Minimum Data Set 3.0 Assessments accurately reflected the residents' status for one (1) of seven (7) residents reviewed for Accidents. Specifically, the Minimum Data Set 3.0 annual comprehensive assessment did not identify Resident #9 as an active smoker.The findings included:An undated facility policy titled Comprehensive Assessment documented information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. Resident #9's diagnoses included nicotine dependence, unspecified paraplegia and bipolar disorder. […]