The Pines Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Aug 29, 2024

  Based on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to insulin administration for 1 (Resident #1) of 3 residents reviewed for newly admitted residents. Specifically, Resident #1 was admitted to a local hospital on 7/19/2024 due to a fall and left upper extremity pain. While at the hospital, the resident was diagnosed with left upper extremity thrombosis and had a necrotic ulcer on the left elbow, which was debrided at the hospital. On 07/31/2024, Resident #`1 was admitted to the nursing home facility with an order for continued anticoagulation (blood thinner) therapy. The resident's nursing home admission diagnosis was embolism or thrombosis of the arteries in the upper extremity. […]

• No harm, potential for more than minimal, widespreadF812Apr 2, 2025

  Based on observation, record review, interview, and facility policy review, the facility failed to ensure expired food items and leftover food items were promptly removed and/or discarded on or before the expiration or use by date, dietary staff washed their hands between dirty and clean tasks and before handling clean equipment, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting meal service for 1 of 1 meals observed. The findings are: 1. On [DATE] at 10:34 AM, Dietary [NAME] (DC) #4 was wearing gloves on his hands when he deboned seven (7) servings of chicken thighs and emptied them into a blender to ground. He brushed spilled pieces of meat crumbs from the counter into his gloved hands, contaminating the gloves. […]

• No harm, potential for more than minimal, widespreadF812Feb 23, 2024

  Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure the ice machine was maintained in clean and sanitary condition to prevent contamination of airborne particles, failed to ensure food items stored in the refrigerator or freezer were sealed, labeled and dated, failed to ensure foods were dated the day received to assure first in, first out usage to prevent potential for food bone illness, failed to ensure expired food items were promptly remove/discarded by the expiration or use by dates, and failed to ensure kitchen floors and kitchen walls were free of stains and chips. […]

• No harm, potential for more than minimal, patternF584Jul 30, 2026

  Based on observations, interviews, facility document review, the facility failed to ensure a sanitary homelike environment for one of one dining area for all residents that occupy the dining area. Based on observations, interviews, and facility document review, the facility failed to ensure a sanitary homelike environment for one of one dining area for all residents that occupy the dining area. The findings include: During the Resident Council session on 07/29/2026 at 9:30 AM, Resident # 50 stated to this surveyor the air intake vent in the dining area was gross and molded. […]

• No harm, potential for more than minimal, patternF693Jul 30, 2026

  Based on observation, record review and interview, the facility failed to ensure enteral feeding bags were labeled appropriately for two (Resident #41 and Resident #81) of three residents reviewed.The findings include:Resident #41:During an observation on 07/27/2026 at 11:55 AM, Resident #41 was sitting in a [brand name] chair, awake, with the head leaned back at an angle. Licensed Practical Nurse (LPN) #3 pushed a feeding pump into the room that was covered with a white pillowcase. LPN #3 was asked to remove the pillowcase. There a was an enteral feeding bag with a brown liquid inside. The enteral bag had, 50/ml) (per/milliliters) [LPN #4 initials] written on the posterior side of the bag. […]