Pine Valley Adult Care Home

The facility failed to ensure 2 of 3 sampled residents were tested for tuberculosis disease upon admission in compliance with required control measures. Specifically, there was no documentation of the required second-step TB test for Resident #2 and Resident #3.

The facility failed to meet the health care needs for 1 out of 3 sampled residents by failing to send the resident to follow-up appointments. After being diagnosed with an infected sacral decubitus ulcer that required surgical debridement, the resident was not sent to follow-up with infectious disease or general surgery.

The facility failed to ensure medications are administered in accordance with infection control protocols.

The facility failed to ensure that 2 of 3 sampled residents were tested for tuberculosis disease upon admission in compliance with required control measures. Specifically, records for Resident #2 and Resident #3 lacked documentation of a second required TB test.

The facility failed to ensure residents could access essential supplies in the common bathrooms. Specifically, toilet paper and paper towels were not kept in the bathrooms, forcing residents to obtain them from the nurses' station or purchase their own. Staff maintained these supplies at the nurses' station to prevent residents from using too much or clogging toilets.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit for 4 of 4 sampled fixtures. Observed temperatures ranged from 126.9 to 132.4 degrees Fahrenheit, posing a significant burn risk to residents.

The facility failed to meet standards regarding food preparation and service requirements as specified in the regulation.

The facility failed to maintain hot water temperatures at a minimum of 100 degrees F and a maximum of 116 degrees F. During the survey, four sampled bathroom sinks were found to have temperatures ranging from 126.9 degrees F to 132.4 degrees F. Weekly temperature logs also indicated that water temperatures in both the men's and women's bathrooms exceeded the safe maximum during January 2023.

The facility failed to maintain hot water temperatures between 100°F and 116°F in the men's common bathroom. Observations confirmed the tub temperature was as low as 83.4°F, and no precautions were posted to warn residents of the lack of hot water.

The facility failed to maintain a safe environment due to live bed bug activity in resident rooms #14 and #20. Additionally, staff used an insecticide incorrectly by not following mixing instructions and using a product not specifically labeled for bed bug control.

The facility failed to ensure the environment was free of hazards, as evidenced by live bed bugs being found in resident rooms #14 and #20. Additionally, staff failed to follow the manufacturer's mixing instructions for an insecticide used to treat the infestation.