St Martin's in the Pines

In the surveyor’s words

From the most serious findings on record at St Martin's in the Pines, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 18, 2025

  Based on observation, interview, record review, and facility document and policy review, the facility failed to prevent a fire in a kitchen near residents. Specifically, kitchen staff placed plastic and foam containers in an oven on the second and third floor kitchens of Cottage B, causing the containers to melt and excessive smoke to [NAME] out of the oven into an area near residents.It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• No harm, potential for more than minimal, isolatedF677Jul 18, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were provided baths/showers for 2 (Resident #70 and Resident #77) of 11 residents reviewed for activities of daily living (ADLs).Findings included:During an interview on 06/29/2025 at 5:53 PM, Director of Clinical Services (DCS) #12 stated they did not have a policy for ADL care; they only had a procedure. An undated form titled, CNA [Certified Nurse Aide] Bath & Shower Report, revealed, The following assessment is to be completed on all residents receiving a bath. The Charge Nurse will sign and verify each assessment for accuracy and completion. […]

• No harm, potential for more than minimal, isolatedF697Jul 18, 2025

  Based on record review, interview, and facility policy review, the facility failed to have an effective pain management program for 1 (Resident #98) of 1 resident reviewed for pain management.Findings included:On 07/18/2025 at 6:03 PM, Corporate Director of Clinical Services (DCS) #12 stated the facility did not have a policy for pain management, but it was the resident's right to be free of pain.An admission Record indicated the facility admitted Resident #98 on 09/05/2024. According to the admission Record, the resident had a medical history that included orthopedic aftercare following surgical amputation of the right leg below the knee, peripheral vascular disease, chronic pain, and anxiety disorder. […]

• No harm, potential for more than minimal, isolatedF656Jan 13, 2022

  Based on interviews, record review, review of a facility policy titled, Incidents/Accidents Policy, review of the facility's investigative file, and review of a Daily Care Guide, the facility failed to ensure Resident Identifier (RI) #1 was transferred on 12/18/2021 with the assist of two staff, using a mechanical lift, as care planned. This deficient practice affected RI #1; one of three residents sampled for transfers. Findings Include: Review of a facility policy titled Incidents/Accidents Policy, with a revised date of 09/2008, revealed the following: . POLICY DIRECTIVES . […]

• No harm, potential for more than minimal, isolatedF689Jan 13, 2022

  Based on interviews, record review, and review of the facility's investigative file, the facility failed to ensure Employee Identifier (EI) #4, a CNA (Certified Nursing Assistant), used a mechanical lift, with the assist of two, as determined necessary by Resident Identifier's (RI) #1's plan of care, during a transfer from the bed to RI #1's wheelchair on 12/18/2021. RI #1 sustained a skin tear to the left arm during this transfer. This deficient practice affected RI #1; one of three residents sampled for transfers. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include [CONDITION(S)] and Difficulty in Walking. RI #1's care plan, with a Problem Onset date of 07/28/2014, revealed: . […]