Pine View Manor Inc

In the surveyor’s words

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

• Actual harm, isolatedF600Apr 13, 2026

  Based on observation, interview, and record review the facility failed to protect one of three sampled residents right to be free from abuse when staff observed Resident #1 and Resident #2 get into a verbal argument, and a short while later, Resident #2 went into Resident #1s room and a physical altercation occurred where both residents were found on the floor. The nurse assessed Resident #1 and found he/she was upset and with physical injuries including a scraped left knee and left elbow and a red mark on the left side of his/her ribs. This affected one of three sampled residents. The facility census was 55. […]

• Actual harm, isolatedF689Oct 5, 2022

  Based on observation, record review and interviews, the facility staff failed to assure Resident #1's safety when the facility staff allowed the resident to remain outside in full sun the afternoon of 9/19/22 from approximately 1:30 P.M. to 3:40 P.M. The high temperature was 94 degrees Fahrenheit. The resident was found outside not responding and sustained a sunburn to the top of his/her head and required hospitalization . This affected one of three sampled resident's. The facility census was 57. Review of the outdoor temperature policy dated 9/28/22 showed: - When the heat index is 100 degrees or above or if the wind chill is 0 degrees or below the staff are supposed to encourage the residents to stay inside. […]

• No harm, potential for more than minimal, widespreadF812May 31, 2024

  Based on observation, interview, and facility policy review, the facility failed to maintain professional standards in the kitchen. Specifically, the facility failed to ensure dented canned foods were not in circulation in 1 of 1 dry storage area observed. This had the potential to affect all 55 residents who resided in the facility and received meals from the kitchen. Findings included: A facility policy titled, Food Receiving and Storage, revised 05/29/2024, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices. […]

• No harm, potential for more than minimal, patternF690May 22, 2025

  2. Review of the Resident #40's Significant Change in Status MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Upper extremity and lower extremity impaired on both sides; - Dependent on the assistance of staff for toilet use; - Had a Foley catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - The resident had seven antibiotics in the last seven days; - Diagnoses included traumatic brain injury, seizure, dementia and depression. […]

• No harm, potential for more than minimal, patternF700May 22, 2025

  Based on observation, record review, and interviews, the facility failed check bed rails regularly to make sure they were still installed correctly as rails may shift or loosen over time. The facility failed to inspect and regularly check the mattress and bed rails for areas of possible entrapment, and failed to include an evaluation of attempted alternatives prior to the installation or use of a bed rail on resident beds. This included three of 12 residents sampled (Resident #1, #33, and #34). […]