Pines Nursing Home

In the surveyor’s words

From the most serious findings on record at Pines Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 7, 2023

  Based on interviews, record review and observation, the facility failed to ensure safety measures were implemented to prevent elopement for one resident (Resident # 1) out of six sampled residents. Resident # 1 eloped from the facility on June 24, 2023. Staff failed to use safety measures to prevent Resident #1's elopement. This unsafe practice has the potential to affect any of the (6) residents residing in the facility that were identifed as an elopement risk. There were 42 residents residing in the facility at the time of the survey. On July 6, 2023, Immediate Jeopardy (IJ) was identified and the Administrator and Director of Nurses were informed of the IJ on 7/6/2023 at 5:05pm. […]

• Immediate jeopardy, isolatedF622Sep 13, 2022

  Based on observation, record review and interviews, the facility failed to provide a safe and appropriate discharge for one (Resident #1) out of three residents reviewed for admission, transfer, and discharge rights. Resident #1 was taken by the Administrator in his personal car to an Assisted Living Facility (ALF), when the ALF refused to admit the resident, the Administrator took the resident to a local hospital's emergency department located approximately 16 miles away from the nursing home and left the resident without any personal belonging, no discharge transfer documents and did not provide the hospital with documentation nor information related to the resident's health status medications and contact information for the resident's representative. […]

• Immediate jeopardy, isolatedF623Sep 13, 2022

  Based on observation, record review and interviews, the facility failed to provide a discharge notice with the resident's signature for three (Resident #1, Resident #4, and Resident #5) out of three residents reviewed for admission, transfer and discharge rights. This has the potential to affect any of the 41 residents residing in the facility at the time of this survey. Refer to F 622, F 639, F 689 and F 835. The findings included: 1) Observation and interview with Resident #1 on 8/16/22 at 8:20 AM revealed the resident had just finished eating breakfast and was sitting in a wheelchair in her room. The resident's left leg was amputated above the knee and the right leg was in a protective boot. […]

• Immediate jeopardy, isolatedF639Sep 13, 2022

  Based on observation, interview, and record review the facility failed to ensure resident care plans, resident assessments and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . As evidenced by Resident #1's discharge, wound/skin and admission assessments were noted to be recorded as late entries ranging from 6 to 92 days later respectively. Resident #1's wounds and care plans contained inaccurate classification and description of Resident #1's wounds and the care plans did not reflect the current treatment process in place for the resident's wound care. […]

• Immediate jeopardy, isolatedF689Sep 13, 2022

  Based on observation, record review and interview the facility failed to implement the facility's policy to ensure adequate supervision is provided to ensure the safety of a vulnerable resident (Resident #1) out of 3 residents reviewed. As evidenced by the Nursing Home Administrator transported Resident #1 in his personal vehicle to an Assisted Living Facility (ALF). When the ALF did not accept the resident, the Administrator took the resident to a local hospital emergency department in another county approximately 16 miles from the nursing home and left the resident without discharge papers, medication, personal belonging and failed to provide the hospital with the resident's current medical status and did not provide contact information for the resident's representative Resident #1 who… […]