Pennsylvania Department of Health
PINE VIEW HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PINE VIEW HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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PINE VIEW HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey completed on March 9, 2026, in response to a complaint at Pine View Healthcare and Rehabilitation Center, it was determined that the facility was not in compliance under the requirement of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of the facility's policy, clinical records review, and staff interview, it was determined that the facility failed to accurately and comprehensively assess and timely provide a wound treatment for two of three residents, reviewed (Resident 1 and 2).

Findings:

A review of the facility's policy titled "Pressure Ulcers/Skin Breakdown-Clinical Protocol", revised in April 2018, revealed that the nursing staff will assess and document an individual's significant risk factor for developing pressure ulcers. The nurse shall describe and document /report a full assessment of the pressure ulcer, including location, stage, length, width, and depth.

A review of Resident 1's readmission skin assessment dated February 9, 2026, revealed an identified skin impairment to the right buttock. The assessment failed to reveal a description of the area/wound and size.

A review of the physician's progress notes dated February 10, 2026, at 2:56 p.m., reveals "Pt (patient) has new small wound on buttock. Wound care follow-up".

Wound assessment to the right buttock, identified on February 9, 2026, was not comprehensively assessed until seen by the wound doctor on February 18, 2026. The wound doctor identified the wound as MASD (Moisture Associated Skin Damage), measuring 2.0 x 1.4 x 0.1 cm, with partial thickness. A wound treatment of Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns).

An interview with the Director of Nursing (DON) was conducted on March 9, 2026, at 1:00 p.m. The DON confirmed that Resident 1's right buttock wound, identified upon readmission on February 9, 2026, was not comprehensively assessed until seen by the wound doctor on February 19, 2026.

A review of Resident 2's readmission skin assessment dated November 9, 2025, revealed scattered scabs on the resident's abdomen and left leg.

A review of Resident 2's skin assessment notes dated November 10, 2025, completed by the wound nurse, licensed Employee E3, revealed a Stage 2 Pressure Ulcer (Partial-thickness skin loss with exposed dermis) to the Sacrum (The triangular bone just below the lumbar vertebrae).

An interview with Employee E3, conducted on March 9, 2025, at 12:30 p.m., revealed that they recheck the resident's skin within 24 hours upon admission to ensure all skin impairments are identified and addressed. Employee E3 confirmed Resident 2 was admitted with a stage 2 to the sacrum on November 12, 2025.

A review of Resident 2's physician's order dated November 13, 2026, revealed an order for Thera Honey (Medihoney) to be applied to the sacrum topically every day shift for the wound.

A review of Resident 2's November 2025 Treatment Administration Record (TAR) failed to reveal that Resident 2's sacral wound was treated until November 15, 2026.

A review of the wound NP's (nurse practitioner) notes dated November 17, 2025, at 8:40 p.m., revealed: "The resident is being evaluated today for a comprehensive skin assessment". The same note revealed, "The patient was noted to have intact skin upon assessment today".

A review of the wound NP's notes dated November 19, 2025, at 5:30 p.m., documented by the same NP from November 17, 2025, revealed: "Patient was seen and evaluated today for PU (pressure ulcer) stage 3 (full-thickness skin loss) to sacrum present on admission fromhospital". The wound had a measurement of 3.0 x 2.0 x 0.2 cm. An order to continue Medihoney was ordered and followed.

An interview was conducted with the DON on March 9, 2026, at 1:00 p.m. The DON confirmed that there was no documented evidence that Resident 2's sacral wound was provided with treatment from readmission (November 12, 2025), until November 14, 2025. In addition, the DON was not aware of the wound NP's November 17, 2025, inaccurate wound assessment/documentation; they reported that the facility has a new wound NP due to multiple concerns/issues with the previous wound NP.

The facility failed to ensure Resident 1 and 2 wounds were accurately and comprehensively assessed, and treatments were timely followed.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Employee R3 was educated on ensuring accurate assessments, complete documentation, and timely treatment orders
2. Identification of Other Residents at Risk:
An audit of all current residents with wounds was completed to ensure accurate assessments, complete documentation, and timely treatment orders. Any discrepancies were immediately corrected
3. Systemic Changes:
- Nursing Management were re-educated on wound assessment requirements.
- Education provided on timely initiation and documentation of treatments per physician orders.
4. Monitoring:
- DON/designee will audit all new admissions/readmissions with skin issues to ensure accurate assessments, complete documentation, and timely treatment orders weekly x4 and monthly x2
- Results will be reviewed in QAPI, and corrective action taken as needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observations, clinical records review, and staff interviews, it was determined that the facility failed to ensure infection control and prevention were implemented during a wound care treatment for two of the two residents reviewed (Resident 1 and 2).

Findings:

A review of Resident 1's physician's order dated March 8, 2026, revealed an order to cleanse the right buttocks with normal saline solution (NSS), pat dry, apply Medihoney (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), and secure with silicone border twice daily for the wound.

An observation of Resident 1's right buttock wound care treatment was conducted on March 9, 2026, at 10:40 a.m., with licensed nurse Employee 3. The observation revealed Employee E3 placed tissue paper on the bed beside the resident and laid the wet gauze, Medihoney in a cup and bordered dressing on top of it. Employee E3 proceeded to clean the right buttock wound with a wet gauze, then discarded it in a trash can. Employee E3 continued to apply Medihoney into the wound and applied the newly opened border without changing their gloves and performing hand hygiene.

A review of Resident 2's physician's order dated November 13, 2026, revealed an order to cleanse the sacrum (The triangular bone just below the lumbar vertebrae), NSS apply Medihoney daily.

An observation of Resident 2's sacrum wound care treatment was conducted on March 9, 2026, at 10:50 a.m., with Employee E3. The observation revealed Employee E3 opened the resident's incontinence brief and assisted in repositioning the resident to their side. Employee E3 laid the cup with a wet gauze inside, the Medihoney (in a medicine cup), and bordered gauze on top of the resident's used incontinence brief in the bed. Employee E3 removed the resident's old sacrum dressing and placed it beside the clean prepared supplies on top of the resident's saoiled incontinence brief. Without changing gloves and washing hands, Employee E3 proceeded to clean the sacrum wound with a wet gauze from the cup, then discarded it back in the same cup. Employee E3 continued applying Medihoney to the wound, then covered it with bordered gauze. Employee E3 did not change gloves and did not perform hand hygiene during the entire procedure.

An interview was conducted with Employee E3 on March 9, 2026, at 12:00 noon. Employee E3 confirmed that wound supplies were placed on the residents' beds because there were no available side tables. Employee E3 also confirmed they were not changing gloves and performing hand hygiene during wound care treatment because they forgot but knew it should have been done.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on March 9, 2026, at 12:30 p.m.

The facility failed to ensure infection control and management were implemented during wound care treatment for Resident 1's right buttock wound and Resident 2's sacral wound.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 04/15/2026

1. Employee R3 was educated on following proper infection control practices
2. Identification of Other Residents at Risk:
All residents receiving wound care were observed/audited to ensure proper infection control practices were maintained. No additional issues identified; any concerns were corrected immediately.
3. Systemic Changes:
- All licensed staff re-educated on infection control practices during wound care.
4. Monitoring:
- DON/designee will audit Wound Care to ensure IC practices are being followed during wound treatments weekly x4 and monthly x2
- Findings will be reviewed in QAPI with corrective action as indicated.

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