Pine View Nursing and Rehab Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jul 23, 2026

  Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation, and Misappropriation, the facility failed to protect one of seven residents' (R11) right to be free from physical abuse from a resident (R10). Actual harm was identified to have occurred on 05/12/2026 when R10 struck R11, causing maxillary sinus and orbit fractures and lacerations to R11's face and scalp. Findings include:Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation, revised 11/28/2017, revealed the section titled, Policy included, It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect,… […]

• No harm, potential for more than minimal, widespreadF804Feb 19, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled, Nutrition Policy, the facility failed to properly prepare pureed food and ensure nutritive value for eight of eight residents receiving a pureed diet. This failure had the potential to serve food at a lesser nutritive value that could cause weight loss.Findings include:Review of the facility's policy titled, Nutrition Policy effective 09/01/2024 revealed under Pureed- Dysphagia Level 1: The pureed consistency is planned according to the regular consistency, but the texture is modified to a smooth, pudding- like texture for all food items. This consistency follows the guidelines as set forth by the National Dysphagia (difficulty with swallowing) Task Force. […]

• No harm, potential for more than minimal, widespreadF812Feb 19, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled, Food Safety and Sanitation, the facility failed to ensure that food was stored in a manner that prevented foodborne illness to the residents, failed to ensure the food was stored at the appropriate temperatures and failed to ensure that dishes and utensils were cleaned under proper sanitary conditions. The deficient practices had the potential to place all residents at risk of acquiring foodborne illnesses. […]

• No harm, potential for more than minimal, widespreadF865Feb 19, 2026

  Based on record review, and staff interviews, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility failed to Maintain and/or produce documentation that demonstrates evidence of its ongoing QAPI program. The deficient practice had the potential to affect resident care outcomes and quality of life for 109 residents.Findings include:A request to review the facility QAPI program documentation, including but not limited to meeting attendance revealed the facility could not produce any documentation for review.A request to review the QAPI policy revealed QAPI policy was not produced for review.Interview on… […]

• No harm, potential for more than minimal, widespreadF880Dec 6, 2024

  Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Hand Hygiene and Legionella Surveillance, the facility failed to ensure staff performed proper infection control practices while serving meals to the residents on two of five halls (D Hall and E Hall). In addition, the facility failed to ensure an effective water management program to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building's water system. The deficient practices had the potential to spread infection by cross-contamination and placed the residents at risk of waterborne illnesses, including Legionnaires disease. The facility census was 97 residents. Findings include: 1. […]