The Pines Healthcare Center

In the surveyor’s words

From the most serious findings on record at The Pines Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 14, 2023

  THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of hospital discharge records, fall investigation and root cause analysis review, resident and staff interviews, facility policy review, and manufacturer's guideline review, the facility failed to provide Resident #50 with a safe transfer using a mechanical lift. Actual harm occurred to Resident #50 when the resident received assistance from two staff members, who failed to use the proper weight capacity lift and used the mechanical lift incorrectly by not widening the base of the lift prior to use, resulting in an avoidable fall with injury including a fractured left distal radius. […]

• Actual harm, isolatedF689Apr 22, 2022

  Based on observation, record review, review of manufacturer's guidelines for bed canes and beds and interview the facility failed to ensure equipment was used properly and within manufacturer's guidelines resulting in a fall with injury for Resident #21. This affected one resident (#21) of three residents reviewed for accidents. Actual Harm occurred to Resident #21 on 04/02/22 when she was using a bed cane for mobility which had a weight limit which Resident #21 exceeded resulting in the bed cane breaking and Resident #21 falling out of bed. The fall resulted in the resident being transferred to the emergency room due to uncontrolled bleeding of a leg wound sustained as a result of the fall which required stitches to the wound. […]

• No harm, potential for more than minimal, widespreadF802Sep 14, 2023

  Based on observation and interview, the facility failed to have sufficient dietary staff to serve meals timely. This had the potential to affect 70 of 70 resident who received meals from the kitchen, as Resident #60 received no food by mouth. The facility census was 71. Findings include: Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook. Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. […]

• No harm, potential for more than minimal, widespreadF804Sep 14, 2023

  Based on record review, observation and interviews the facility failed to ensure food was served at a palatable temperatures. This had the potential to affect 70 of 70 resident who received food from the kitchen, as Resident #60 received no food by mouth. The facility census was 71. Findings include: Interviews on 09/11/23 from 9:00 A.M through 11:30 A.M. during the screening process for the annual survey with multiple residents (# 9, #13, #16, #17, #19, #, 26, #36, #38, #45, #58, #64, #171 and #175) revealed concerns with dietary including palatability of meals. Observation and interview on 09/12/23 at 11:35 A.M. revealed the hot food on the steam table had temperatures over 165 degrees. A test tray left the steam table at 12:15 P.M. The test tray was served last at 12:34 P.M. […]

• No harm, potential for more than minimal, widespreadF809Sep 14, 2023

  Based on observation and interview, the facility failed to serve meals in a timely manner. This had the potential to affect 70 of 70 residents who received food from the kitchen. Resident #60 received no food by mouth. The facility census was 71. Findings include: 1. Review of the facility dining times revealed the lunch meal was to start serving at 11:30 A.M. Interview on 09/11/23 at 8:30 A.M. with Registered Dietician (RD) #900 revealed three dietary staff called off work today including the cook. She stated the Food Service Director (FSD) #867 was acting as the cook. Interview on 09/11/23 at 8:47 A.M. with Social Service Designee (SSD) #805 revealed she was assisting with meal service due to three call-offs. […]