Inspection Reports for Pine Acres Alr

The complaint investigation was substantiated with findings of abuse, neglect, and financial exploitation involving Staff A and other staff members. The facility failed to timely report incidents and protect residents from abuse. Staff A was suspended and later terminated. Other staff were retrained and disciplinary actions were taken.

The investigation found that the facility failed to report incidents of alleged abuse within 24 hours as required, and there were multiple incidents involving staff-resident relationships, verbal abuse, financial exploitation, and failure to protect residents from abuse. Staff members were suspended or terminated, and corrective actions including staff retraining and policy enforcement were planned.

The investigation was complaint-driven, referencing ACTS numbers 98145 and 98146. The complaint was substantiated as a deficiency was identified related to food safety certification compliance.

The facility failed to ensure that all food services were conducted in accordance with food safety certification requirements. Specifically, the facility did not have a staff member certified in food safety scheduled at all times when potentially hazardous food was prepared, and only the Kitchen Manager was certified. A newly hired kitchen staff member was not certified, and meals requiring preparation by certified staff were identified.

The visit included a complaint/incident investigation survey conducted on 07/30/2024. Findings included staffing deficiencies related to uncertified staff providing personal care, incomplete resident records, inadequate wound care documentation, and food safety violations.

The facility failed to provide sufficient staffing with certified nursing assistants, maintain complete and accurate resident records, and ensure proper documentation of wound care and resident assessments. Additionally, the facility lacked a certified food safety manager and failed to comply with food safety regulations.

The complaint was submitted on 2024-03-25 alleging that Staff A and Staff B lived in the same room as Resident ID #1. Surveyor observations on 2024-04-09 confirmed the presence of staff belongings and beds in the resident's room. Resident ID #1 was unwilling to report about roommates. The administrator interview on 2024-04-10 confirmed staff presence in the room and inability to prove resident rights were observed.

The investigation found that the residence failed to observe the 'Rights of Residents' for one resident (ID #1), specifically regarding privacy and room sharing. Staff A and Staff B were alleged to have lived in the same room as the resident, which was confirmed by observations and interviews. The administrator could not provide evidence that the resident's rights were observed as required.

The investigation was triggered by a complaint regarding medication administration failures for Resident #1, including missed doses of Hydromorphone and lack of licensed nurse availability. The complaint was substantiated based on record reviews and staff interviews.

The facility failed to provide a licensed nurse to administer needed medications to Resident #1, specifically a schedule II controlled substance, Hydromorphone. The medication was not administered as prescribed, and the facility lacked proper procedures and secure storage for medications, including locked medication boxes. Staff, including the administrator, were reeducated and corrective actions were planned.

The investigation was triggered by complaints and incident reports involving Staff D, including allegations of verbal abuse, poor treatment of residents, and failure to complete required background checks timely. Staff D was suspended and later terminated due to multiple allegations. Complaints were received from the Alliance and residents regarding Staff D's treatment.

Deficiencies were identified including failure to ensure national criminal background checks were completed within one week of hire for three employees, failure to provide all care and services consistent with community standards for medication administration, failure to protect residents' rights including verbal abuse allegations, failure to employ certified food safety managers, and failure to comply with fire safety inspection requirements.

The visit was complaint-related, investigating allegations regarding employee training and background checks. The complaint was substantiated as deficiencies were identified.

The facility failed to ensure that a newly hired employee (Staff A) received all required orientation and in-service training within the required timeframes and did not have documentation of a criminal background check prior to or within seven days of hire. Staff interviews and record reviews confirmed these deficiencies.

The visit was triggered by a complaint/incident investigation. Deficiencies were identified related to resident assessments, service plans, and medication administration. The complaint was substantiated based on record reviews and staff interviews.

The facility failed to update comprehensive assessments annually or when residents' conditions changed, did not complete required nurse reviews, and failed to ensure proper medication self-administration assessments and documentation. The facility also did not accommodate special diets and lacked evidence of medication self-assessment completion by residents.