Pine View Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF600Sep 2, 2022

  Based on facility policy and procedure review, staff and resident interview, facility documentation review, and clinical record review it was determined the facility failed to ensure that one of 32 residents was free from neglect during care resulting in actual harm causing a skin tear requiring emergency room visit and suture repair. This deficiency is cited as past noncompliance. (Resident 134) Findings Include: Review of facility policy and procedure titled Abuse and Neglect, revised July 2017, revealed a definition of neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. […]

• Actual harm, isolatedF686Sep 2, 2022

  Based on clinical record review and staff interview it was determined the facility failed to monitor and provide interventions to prevent the worsening of a newly discovered pressure ulcer for one of 5 residents reviewed resulting in actual harm to Resident 67. Findings Include: Review of Resident 67's Braden Scale Assessment (Assessment used to determine a residents risk for developing a pressure ulcer) dated November 14, 2021, revealed the resdient was at risk for developing pressure ulcers. Review of Resident 67's care plan revealed a care plan initiated November 14, 2021, for at risk for pressure ulcer developement related to immobility. […]

• Actual harm, isolatedF684Jul 30, 2021

  Based on review of the facility policy, clinical records, facility documentation, hospital records, resident and staff interviews, it was determined that the facility failed to follow a physician's order, administer medications per physician, thoroughly assess and notify the attending physician timely of a resident's change in condition, for four (Resident 112, 124, 134, and 137) of 30 residents reviewed. The failure to thoroughly assess and subsequently notify attending physician of the change in condition resulted in actual harm to Resident 134, requiring hospitalization in an Intensive Care Unit (specialized care unit within a hospital that provides extensive care treatment). Findings include: Review of Resident 134's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF686Jul 30, 2021

  Based on policy and clinical record review, interview, and observation, it was determined that the facility failed to timely identify a pressure ulcer for one of six residents reviewed (Resident 116) which resulted in actual harm to Resident 116 who developed an unstageable pressure ulcer to the left heel which caused the resident pain and required debridement. Findings include: Review of facility policy, Skin Management, last revised July 2017 revealed that the Braden Scale for Predicting Pressure Ulcer Risk should be completed quarterly. The policy also revealed that weekly skin checks will be completed in the resident's record. Interview with Resident 116 on July 27, 2021 at 9:54 a.m. […]

• Actual harm, isolatedF697Jul 30, 2021

  Based on observation, resident and staff interview, and clinical records review, it was determined that the facility failed to administer physician ordered routine pain medication for one (Resident 354) of six residents reviewed. The failure to administer routine pain medications (12:00 a.m., and 6:00 a.m.) resulted in actual harm in Resident 354 who experienced a generalized severe body pain of 10/10. Findings include: Review of Resident 354's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 354's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care), dated July 23, 2021, revealed that the resident was cognitively intact with no documented behavior. […]