The Pines Post Acute and Memory Care

In the surveyor’s words

From the most serious findings on record at The Pines Post Acute and Memory Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF604May 1, 2025

  Based on staff interview and record review, the facility did not ensure 1 resident (R) (R1) of 3 sampled residents was free from being physically restrained. R1 had Alzheimer's disease and had a history of tearing apart R1's incontinence brief. On the 4/1/25 PM shift at approximately 9:30 PM, Certified Nursing Assistant (CNA)-C tied the sleeves of R1's nightgown closed with R1's arms inside and tucked a blanket across R1's lap and under both sides of the mattress after R1 repeatedly tried to rip off R1's brief. R1 was restrained in bed until approximately 12:10 AM when staff on the next shift did a routine check on R1. R1 was restrained in such a way that R1 could not access R1's hands or call light and could not move freely in bed. […]

• Actual harm, isolatedF689Jun 19, 2025

  2. On 6/19/25, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE] and had a diagnosis of Parkinson's disease. R2's MDS assessment, dated 5/2/25, had a BIMS score of 9 out of 15 which indicated R2 had moderate cognitive impairment. R2 had a POAHC. R2's care plan indicated the following: ~ Sensor alarm to bed and chair to alert staff of self-ambulating so staff can assure R2 is using R2's walker ~ Do not put feet up in recliner, unable to put down independently Surveyor reviewed a fall investigation that indicated R2 was found on the floor of R2's room on 4/27/25 at 6:15 PM. CNA staff had assisted R2 to bed less than five minutes prior. […]

• No harm, potential for more than minimal, patternF761Jul 17, 2025

  Based on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. One of three medication carts was observed unlocked and unattended during medication administration. This practice had the potential to affect more than 4 of the 44 residents residing in the facility.The Memory Lane medication cart was unlocked and unattended during medication administration on 7/17/25. Findings include:The facility's Medication Storage policy indicates: .b.Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.On 7/17/25 at 9:35 AM, Surveyor noted the medication cart on Memory Lane was unlocked and unattended. […]

• No harm, potential for more than minimal, patternF812Jul 17, 2025

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 44 residents residing in the facility.Staff did not test the parts per million (PPM) of the Quaternary sanitizing solution per the manufacturer's instructions.The reach-in cooler did not maintain a consistent and safe temperature for items that required storage at 41 degrees Fahrenheit (F) or below.The reach-in cooler contained unlabeled, undated, and/or expired items.Findings include:On 7/15/25, Lead [NAME] (LC)-D indicated the facility follows the Wisconsin Food Code. […]

• No harm, potential for more than minimal, patternF761May 15, 2024

  Based on observation, staff interview, and record review, the facility did not ensure 1 of 2 refrigerators in the medication storage room that contained vaccines and insulin maintained a temperature between 36 and 46 degrees. In addition, the facility did not ensure medications for 11 residents (R) (R23, R41, R11, R9, R12, R13, R32, R39, R7, R35, and R30) of 49 residents in 3 out of 3 medications carts were labeled and/or dated appropriately. Refrigerator temperature log sheets indicated temperatures were more than 46 degrees for a refrigerator in the medication storage room. During observations on [DATE], the thermometer in the refrigerator indicated the temperature was 52 degrees and 54 degrees. […]