Pine View Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 4, 2023

  Based on interview and record review the facility failed to ensure residents were free from abuse. R1 had a known history of inappropriately touching female residents. R1 was observed touching R2 and R3 in an inappropriate manner. On 12/1/22 R1 was witnessed to touch R3's arm and breast. The facility failed to: perform an assessment of R3; document monitoringm of R3's for behavior changes; ensure R3 and other resident safety after incident; and update R3's care plan timely. On 12/2/22, R1 was witnessed to kiss R2. On 12/10/22, R1's care plan was not followed and R1 was unsupervised and witnessed by staff in R2's room with R2's pants down. The facility was aware of R1 behaviors of inappropriate physical/sexual contact with other residents. […]

• Immediate jeopardy, isolatedF689Jan 4, 2023

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R1, R2, and R3) reviewed for supervision and resident to resident altercation. R1 has a known history of inappropriately touching other residents. The facility implemented an intervention of line of sight supervision. That supervision was not consistently provided allowing R1 the opportunity to again seek out residents and inappropriately touch them on multiple dates. After 3 incidents, all of which occurred while R1 was supposed to be under line of sight supervision, the facility implemented 1 to 1 supervision. […]

• Immediate jeopardy, isolatedF689Sep 15, 2022

  Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care )(APOAHC). R1 has attempted to elope from the facility every day, and sometimes multiple times per day. R1 eloped from the facility on 8/12/22. R1 was missing for one and a half hours with the facility staff unable to locate R1. The facility made no changes in R1's Care Plan to prevent elopement or provide increased supervision. An alarmed door was found with the alarm disabled during the survey on 9/1/22. […]

• Immediate jeopardy, isolatedF812Feb 17, 2022

  Based on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety to prevent foodborne illness for 1 of 12 sampled resident (R28) and 1 of 1 supplemental residents (R13) who were served non-pasteurized eggs with runny yolks that were not set and completely firm. Failure to ensure that eggs served were pasteurized or fully cooked placed these residents at risk for becoming infected by Salmonella and created a finding of Immediate Jeopardy (IJ) beginning on 2/15/22. The NHA A (Nursing Home Administrator) was informed of the Immediate Jeopardy on 2/15/22 at 11:00 AM. […]

• Actual harm, isolatedF689Jan 12, 2023

  Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 2 of 5 residents reviewed (R28 and R35) of a total sample of 12. R28 has a history of multiple falls. R28 is resistive to assistance and frequently self-transfers despite the risk of fall with major injury. R28 requested assistance to the use the bathroom from a non-direct care staff member on 9/28/22. The staff member noted that R28's pants were lowered when asking for assistance. The staff member did not remain with R28 until assistance was available. […]