Deficiencies per Year
80
60
40
20
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 18, 2025
Visit Reason
A revisit of the surveys ending October 22, 2025 and November 4, 2025 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 9, 2025.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Nov 25, 2025
Visit Reason
The inspection was conducted as a result of complaints #2654183-C, #2654729-C, and #2657936-C, investigating quality of care issues at Pine Acres Rehabilitation and Care Center between October 29, 2025 and November 4, 2025.
Findings
The facility failed to provide timely assessment and intervention for 2 of 3 residents reviewed, including failure to respond to changes in condition and failure to notify providers timely. Additionally, the facility failed to provide treatments as ordered by a physician for 1 of 3 residents, resulting in medication errors and improper wound care.
Complaint Details
Complaints #2654183-C, #2654729-C, and #2657936-C were substantiated resulting in deficiencies related to quality of care and medication errors.
Severity Breakdown
G: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide timely assessment and intervention for residents, including failure to respond to changes in condition and failure to notify providers. | G |
| Failure to provide treatments as ordered by a physician, including medication errors and improper wound care. | D |
Report Facts
Census: 85
Complaints investigated: 3
Residents reviewed for assessment: 3
Residents with medication/treatment errors: 1
Residents with delayed assessment/intervention: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Stated medication administration details for Resident #1 |
| Staff B | Certified Nurse Aide (CNA) | Reported Resident #1 condition and care details |
| Staff C | Licensed Practical Nurse (LPN) | Instructed care for Resident #1 and reported observations |
| Staff F | Registered Nurse (RN) | Observed Resident #1 condition and reported concerns |
| Staff G | Registered Nurse (RN) | Responded to Resident #1 emergency and hospital transfer |
| Staff H | Licensed Practical Nurse (LPN) | Entered medication orders and confirmed medication administration process |
| Staff J | Licensed Practical Nurse (LPN) | Described medication administration verification process |
| Regional Director of Operations | Acknowledged medication error and expectations for correction | |
| ARNP | Advanced Registered Nurse Practitioner | Provided documentation and clinical input regarding Resident #1 |
| DON | Director of Nursing | Reviewed medication orders and participated in corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 25, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #2628715-C, #2628758-C, and #2631306-C from October 20 to October 22, 2025, focusing on medication administration and resident safety.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically related to the improper removal and application of fentanyl patches for Resident #3, leading to a fentanyl overdose and hospitalization. Multiple staff interviews and record reviews confirmed lapses in medication management and documentation.
Complaint Details
The deficiency resulted from investigation of complaints #2628715-C, #2628758-C, and #2631306-C. The complaint related to medication errors was substantiated as evidenced by clinical record review, staff interviews, and resident condition.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow physician orders to remove a fentanyl patch prior to applying a new patch for Resident #3, resulting in a medication error and fentanyl overdose. | Level D |
Report Facts
Deficiency correction date: Dec 9, 2025
Fentanyl patch dosage: 25
Dates of complaint investigation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Advanced Registered Nurse Practitioner (ARNP) | Assessed Resident #3 and noted lethargy and confusion; involved in resident's hospital transfer |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding fentanyl patch application and disposal procedures |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 22, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction following acceptance of credible allegation of substantial compliance and Plan of Correction.
Findings
The facility will be certified in compliance effective September 19, 2025, based on acceptance of credible allegation of substantial compliance and Plan of Correction.
Deficiencies (1)
| Description |
|---|
| Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction. |
Report Facts
Certification effective date: Sep 19, 2025
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 4
Aug 26, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#1757001-C, #2567676-C, #2582029-C) and facility reported incidents (#2591845-I and #2598449-I) from August 18 to August 26, 2025.
Findings
The facility was found deficient in maintaining a safe, clean, comfortable, and homelike environment, proper bowel and bladder incontinence care including catheter management, sufficient nursing staff, and infection prevention and control practices. Specific issues included stained carpet and ceiling tiles, inadequate cleaning, improper catheter care, delayed response to call lights, and failure to maintain infection control protocols.
Complaint Details
The deficiencies resulted from investigations of complaints #1757001-C, #2567676-C, and #2582029-C, which were substantiated as evidenced by the cited deficiencies.
Severity Breakdown
E: 3
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to maintain a safe, clean, comfortable, and homelike environment including stained carpet, peeling paint, dirty vents, and poor maintenance. | E |
| Failure to provide appropriate bowel and bladder incontinence care, including catheter care and perineal hygiene. | D |
| Insufficient nursing staff to assure resident safety and timely response to call lights. | E |
| Failure to establish and maintain an infection prevention and control program, including hand hygiene and catheter care. | E |
Report Facts
Complaints investigated: 3
Facility reported incidents: 2
Residents census: 79
Residents reviewed for nursing staff deficiency: 5
Residents reviewed for incontinence care deficiency: 3
Residents reviewed for infection control deficiency: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wheelchair cleaning expectations and catheter care |
| Staff A | Certified Nursing Assistant (CNA) | Observed providing care including cleansing resident and handling catheter |
| Staff B | Certified Nursing Assistant (CNA) | Observed assisting residents during lunch and infection control practices |
| Staff C | Certified Nursing Assistant (CNA) | Observed providing perineal care and emptying catheter bag |
| Staff F | Certified Nursing Assistant (CNA) | Observed providing catheter care and infection control |
| Staff G | Registered Nurse (RN) | Interviewed regarding ostomy care and infection control |
| Maintenance Director | Maintenance Director | Interviewed about facility maintenance and cleaning practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 9, 2025
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification effective July 9, 2025.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 10
Jun 9, 2025
Visit Reason
The inspection was a special focus recertification survey and investigation of complaints #128433-C and #128732-C conducted from June 6, 2025 to June 9, 2025. Complaint #128433-C resulted in a deficiency.
Findings
The facility was found deficient in multiple areas including discharge process documentation, accuracy and coordination of PASARR assessments, comprehensive care plan development and revision, accident hazards and supervision, medication management, medication labeling and storage, infection prevention and control, and quality assurance performance improvement (QAPI) program. Several deficiencies were repeat citations from prior surveys.
Complaint Details
Complaint #128433-C resulted in a deficiency. Complaint #128732-C did not result in a deficiency.
Severity Breakdown
SS=D: 8
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to document a resident's transfer to the hospital, physician and family notification, and bed hold for 1 of 3 residents reviewed (Resident #7). | SS=D |
| Failed to accurately complete a Minimum Data Set (MDS) Assessment by not identifying a resident had a serious mental illness as considered by the state level II PASARR for 1 of 16 residents (Resident #34). | SS=D |
| Failed to submit an updated PASARR evaluation for 1 of 4 residents reviewed with mental health diagnosis and medications (Resident #31). | SS=D |
| Failed to develop and implement a comprehensive person-centered care plan for 1 of 20 residents reviewed (Resident #25), specifically lacking toileting hygiene interventions and goals. | SS=D |
| Failed to revise the comprehensive care plan to accurately reflect status of 1 of 20 residents reviewed (Resident #48) after a fall resulting in fractured clavicle and weight bearing as tolerated (WBAT) order. | SS=D |
| Failed to ensure resident environment was free from hazards and provide adequate supervision to prevent accidents for 2 of 4 residents reviewed (Resident #75 and #5). Resident #75 smoked without supervision or wearing a smoking apron contrary to policy. Resident #5 left the facility without notifying staff or signing out. | SS=D |
| Failed to ensure knowledge and techniques necessary to care for residents' medication management in a timely manner for 1 of 5 residents reviewed (Resident #31), including failure to process a gradual dose reduction order. | SS=D |
| Failed to safely store and label resident's medications, including undated stock medications and medication cups left prepared on medication cart. | SS=D |
| Failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Observed staff serving drinks and food without proper hand hygiene, cross contamination during meal service, and failure to clean shared resident-care equipment between uses. | SS=E |
| Failed to maintain an effective QAPI program to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the current survey. | SS=E |
Report Facts
Deficiencies cited: 10
Resident census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Aide | Named in medication storage and labeling deficiency for leaving undated medications on medication cart. |
| Staff E | Dietary Staff | Named in infection control deficiency for improper hand hygiene while serving drinks. |
| Staff F | Certified Nursing Assistant | Named in infection control deficiency for cross contamination during meal service. |
| Staff H | Registered Nurse | Named in accident supervision deficiency related to resident elopement incident. |
| Staff I | Registered Nurse | Named in accident supervision deficiency related to resident elopement incident. |
| Corporate Nurse | Interviewed regarding failure to document hospital transfer and bed hold for Resident #7. | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication management, infection control, care plan revisions, and resident supervision. |
| Staff D | Social Services | Interviewed regarding PASARR coordination and smoking assessments. |
| Staff G | Administration | Interviewed regarding PASARR coordination. |
Inspection Report
Plan of Correction
Deficiencies: 0
May 29, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective May 29, 2025.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Apr 28, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#127400-C, #127922-C, #128202-C) and a facility-reported incident (#128238-I) from April 28, 2025 to May 1, 2025.
Findings
The facility was found deficient in quality of care related to failure to provide assessments, obtain orders, or follow up with a physician for a resident with a central line. Additionally, the facility failed to ensure an effective behavioral health program for a resident with substance use disorder, including lack of staff training and inadequate care plans.
Complaint Details
The visit was complaint-related involving Complaints #127400-C, #127922-C, #128202-C, and a facility-reported incident #128238-I. Complaints #127922-C and #128202-C resulted in deficiencies.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide assessments, obtain orders, or follow up with physician on a resident with an identified central line. | SS=D |
| Facility failed to ensure the behavioral health program was effective for a resident with Substance Use Disorder, including lack of staff training and inadequate care plans. | SS=D |
Report Facts
Census: 65
BIMS score: 14
BIMS score: 15
Drug test count: 1
Date of Compliance: May 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Erin Martin | ARNP | Provided orders to remove Resident #2's central line prior to survey |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 3, 2025
Visit Reason
A revisit of the survey ending December 19, 2024, and investigation of Complaints #125824-C, #125825-C, and #126311-C was conducted from February 03, 2025 to February 06, 2025.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 23, 2025. Complaints #125824-C, #125825-C, and #126311-C were not substantiated.
Complaint Details
Complaints #125824-C, #125825-C, and #126311-C were investigated and found not substantiated.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 13
Jan 23, 2025
Visit Reason
Annual Recertification Survey conducted from December 2, 2024 to December 19, 2024 to assess compliance with federal regulations for Pine Acres Rehabilitation and Care Center.
Findings
The survey identified multiple deficiencies including failure to complete background checks prior to rehire, incomplete comprehensive care plans addressing medications and smoking, inaccurate care plan timing and revisions, inconsistent code status documentation, failure to provide diabetic shoes, inadequate supervision and safety measures for smoking residents, incomplete dialysis assessments, insufficient nursing staff response to call lights, incomplete food temperature and sanitation logs, unsanitary food storage, improper catheter care leading to UTI risk, and incomplete immunization documentation for influenza, pneumococcal, and COVID-19 vaccines.
Severity Breakdown
SS=D: 7
SS=E: 3
SS=J: 1
: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to complete criminal record and abuse registry check prior to employee rehire date. | — |
| Care plans failed to address high risk medications such as insulin and antidepressants and failed to follow care plan regarding smoking materials. | SS=D |
| Failed to fully review and revise comprehensive care plans when residents had changes in advance directives and smoking status. | SS=E |
| Failed to provide physician orders related to code status and accurately document in clinical records for residents. | SS=D |
| Failed to ensure resident received diabetic shoes as ordered, resulting in foot ulcer and amputation. | SS=J |
| Failed to provide adequate supervision and safety devices for residents who smoke and failed to use foot pedals when transferring resident in wheelchair. | SS=E |
| Failed to consistently perform required pre-dialysis and post-dialysis assessments for a resident receiving dialysis. | SS=D |
| Failed to provide sufficient nursing staff to respond timely to resident call lights and needs. | SS=D |
| Failed to ensure food prepared and maintained at appropriate temperature and dishes sanitized properly due to incomplete logs. | SS=E |
| Failed to ensure food stored in sanitary manner to prevent contamination including debris in freezer, uncovered fryer oil, and unlabeled cereal containers. | SS=E |
| Failed to implement infection control practices during catheter care to prevent urinary tract infection. | SS=D |
| Failed to ensure residents were provided influenza and pneumococcal immunizations or documentation of refusal or contraindication. | SS=D |
| Failed to ensure residents were provided COVID-19 immunizations or documentation of refusal or contraindication. | SS=D |
Report Facts
Census: 61
Meals with incomplete food temperature logs: 24
Meals with incomplete food temperature logs: 24
Meals with incomplete food temperature logs: 13
Dishmachine logs missing sanitizer verification: 8
Dishmachine logs missing sanitizer verification: 16
Residents reviewed for immunizations: 5
Residents reviewed for dialysis: 1
Residents reviewed for staffing: 1
Residents reviewed for smoking supervision: 3
Residents reviewed for catheter care: 1
Residents reviewed for diabetic foot care: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse | Named in background check deficiency related to rehire date |
| Staff H | Social Worker | Named in care plan and code status deficiencies |
| Staff M | MDS Coordinator | Named in care plan and code status deficiencies |
| Staff G | Shoe Vendor Office Manager | Named in diabetic shoe deficiency |
| Staff F | Medical Doctor | Named in diabetic shoe deficiency |
| Staff D | Certified Nursing Assistant | Named in smoking supervision and call light response deficiencies |
| Staff C | Certified Nursing Assistant | Named in smoking supervision deficiency |
| Staff K | Certified Medication Aide | Named in smoking supervision deficiency |
| Staff B | Certified Nurse Aide | Named in catheter care deficiency |
| Staff A | Registered Nurse | Named in dialysis assessment deficiency |
| Staff I | Certified Medication Aide | Named in code status deficiency |
| Staff J | Licensed Practical Nurse | Named in code status deficiency |
| Staff L | Registered Nurse | Named in smoking supervision deficiency |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 20, 2024
Visit Reason
A revisit of the survey ending October 10, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 17, 2024.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 20, 2024
Visit Reason
A revisit of the survey ending October 10, 2024 and October 31, 2024 was conducted on November 20, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 17, 2024.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Oct 31, 2024
Visit Reason
Investigation of complaint #124347-C and facility reported incidents #124267-I and #124302-I conducted from October 23 to October 31, 2024, related to resident elopement and supervision concerns.
Findings
The facility failed to provide adequate supervision to prevent a cognitively impaired resident at risk for elopement from leaving the facility unsupervised, resulting in a fall and serious injury. The facility implemented corrective actions including re-evaluation of residents at risk, education of staff, and door/alarm inspections. The resident was found approximately 0.2 miles away after eloping and suffered C1 and C2 fractures.
Complaint Details
Complaint #124347-C was substantiated. Facility reported incidents #124267-I and #124302-I were substantiated. Immediate Jeopardy (IJ) was identified starting 10/21/24 and removed on 10/29/24 after corrective actions.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were adequately supervised to prevent elopement, resulting in a resident leaving the facility unsupervised and sustaining injury. | SS=J |
Report Facts
Resident elopement distance: 0.2
Resident census: 68
Elopement risk assessment score: 20
Fall risk assessment score: 13
Date of incident: Oct 21, 2024
Date of survey completion: Oct 31, 2024
Date of plan of correction completion: Nov 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Completed Admission Assessment for Resident #1. |
| Staff B | Licensed Practical Nurse | Completed Elopement Risk Assessment and responded to elopement alarm. |
| Director of Nursing | Director of Nursing | Named in investigation and corrective actions related to elopement incident. |
| Staff C | Certified Nursing Assistant | Provided statement regarding resident supervision. |
| Staff D | Director of Recreation | Provided statement and checked wander guard functionality. |
| Staff J | Registered Nurse | Responded to EMS and elopement incident. |
| Staff K | Supervisor with Hospice | Reported hospice visits and notification of elopement. |
| Staff N | Described procedures for locating missing residents and alarm response. | |
| Staff O | Certified Nursing Assistant | Described missing resident protocol and alarm response. |
| Staff P | Certified Nursing Assistant | Described elopement drill and missing resident search procedures. |
| Staff Q | Licensed Practical Nurse | Described alarm response and missing resident protocol. |
| Staff R | Social Services | Described alarm response and communication procedures. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Oct 10, 2024
Visit Reason
The inspection was conducted from October 8 to October 10, 2024, as a result of investigations into multiple complaints (#121793-C, #123482-C, #123607-C, #123870-C) and a facility reported incident (#121998-I). Complaints #123607-C and #123870-C and the facility incident #121998-I were substantiated.
Findings
The facility failed to ensure that Resident #2 was free from accident hazards, resulting in multiple falls within three days, including a fall that caused a right hip fracture. Despite interventions such as gripper socks and call light modifications, the resident self-transferred without assistance and did not consistently use safety measures, leading to injury.
Complaint Details
The investigation was triggered by complaints #121793-C, #123482-C, #123607-C, #123870-C and a facility reported incident #121998-I. Complaints #123607-C and #123870-C and the facility incident #121998-I were substantiated.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #2 was free from accident hazards, resulting in multiple falls and a right hip fracture. | SS=G |
Report Facts
Resident census: 68
Falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided statements regarding Resident #2's falls and interventions |
| Administrator | Administrator | Provided statements regarding care plan interventions after Resident #2's falls |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 19, 2024
Visit Reason
The document is a plan of correction submitted by the facility following a survey to address deficiencies and demonstrate compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective July 19, 2024.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 5
Jun 19, 2024
Visit Reason
The inspection was conducted as an investigation of Complaints #120257-C, #121407-C, and Facility Reported Incident #121444-I from June 11 to June 19, 2024. The complaints and incident were substantiated.
Findings
The facility failed to provide care and services according to accepted professional standards for multiple residents, including failure to obtain labs per physician orders, inadequate nursing supervision to prevent falls, improper incontinence care, failure to provide oxygen therapy as ordered, and failure to arrange transportation for physician appointments.
Complaint Details
The visit was triggered by substantiated complaints #120257-C and #121407-C, and a substantiated facility reported incident #121444-I.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide care and services according to accepted standards for 2 of 3 residents by not obtaining labs per physician orders. | SS=D |
| Failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents related to falls. | SS=D |
| Failed to provide appropriate incontinence care for 1 of 3 residents reviewed. | SS=D |
| Failed to provide oxygen according to physician orders for 3 of 4 residents reviewed. | SS=D |
| Failed to arrange and/or provide transportation services to physician appointments for 2 of 3 residents reviewed. | SS=D |
Report Facts
Residents reviewed: 3
Residents reviewed: 4
Resident census: 55
Fall Risk Assessment score: 18
Oxygen liters ordered: 5
Oxygen liters observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | LPN | Reported Resident #2's portable oxygen tank was empty on 12/4/23 and switched to concentrator |
| Staff B | LPN | Reported unfamiliarity with Vikor urine specimen collection and verified empty oxygen tank for Resident #6 |
| Staff D | CNA | Observed providing incontinence care with deficiencies and reported assisting Resident #6 without checking oxygen tank |
| Staff F | CNA | Observed providing inadequate incontinence care with improper glove use and hand hygiene |
| Staff G | Transportation Aide | Rescheduled Resident #3's appointment and reported late notification of appointment |
| DON | Director of Nursing | Verified missing lab results, inadequate supervision, improper incontinence care, and oxygen therapy failures |
| Senior Manager | Transportation Company | Reported Resident #2 was not scheduled for transportation on missed appointment dates |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 22, 2024
Visit Reason
The document serves as a Plan of Correction following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective April 22, 2024.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Mar 25, 2024
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#119460-C, #119294-C, #119688-C, #119913-C) and a facility reported incident (#119484-I) from March 25, 2024 to April 3, 2024.
Findings
The facility failed to meet professional standards in providing services, including failure to administer medications as ordered for residents and failure to provide adequate bathing care for dependent residents. The complaints #119294-C and #119688-C were substantiated.
Complaint Details
Complaints #119294-C and #119688-C were substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to give medications as directed per physician orders for 2 or 4 residents reviewed. | SS=D |
| Facility failed to provide two baths a week as directed for 3 out of 4 residents reviewed. | SS=D |
Report Facts
Residents reviewed: 4
Residents affected: 2
Residents affected: 3
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Reviewed MAR & TAR, labs, and implemented corrective actions related to medication and bathing deficiencies |
| Interim Administrator | Stated expectation that staff follow physician orders and verified bathing schedules |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 20, 2024
Visit Reason
The state survey agency conducted an investigation into intake 112264-M, which ended on August 31, 2023.
Findings
The survey staff did not identify any deficiencies during the investigation.
Complaint Details
Investigation into intake 112264-M ended with no deficiencies identified.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 1, 2024
Visit Reason
A revisit of the survey ending December 21, 2023 and investigation of multiple complaints and facility reported incidents was conducted from January 29, 2024 to February 1, 2024.
Findings
All deficiencies identified in the prior survey and complaint investigations were corrected, and the facility was found to be in substantial compliance effective January 25, 2024.
Complaint Details
The visit included investigation of Complaints #117895-C, #117898-C, #118139-C, #118296-C, #118427-C, #118524-C and Facility Reported Incidents #118326-I and 118465-I. All deficiencies were corrected.
Report Facts
Denial of Payment for Admissions (DPNA) duration: 110
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 7
Dec 21, 2023
Visit Reason
A revisit of previous surveys and investigation of multiple complaints and facility reported incidents was conducted from December 11, 2023 to December 21, 2023. Several complaints and incidents were substantiated.
Findings
The facility was found deficient in multiple areas including failure to follow physician's orders for wound care and medication administration, failure to reorder medications timely, failure to provide adequate incontinence care, failure to ensure call lights were accessible to residents, failure to keep medication and treatment carts locked, and failure to maintain an effective infection prevention and control program. Repeated deficiencies were noted from prior surveys.
Complaint Details
The visit was triggered by multiple complaints (#116722-C, #116928-C, #117063-C, #117159-C, #117385-C) and facility reported incidents (#116474-I, #116931-I). Complaints #116722-C, #116928-C, #117063-C, #117159-C, and #117385-C were substantiated. Facility reported incident #116474-I was substantiated.
Severity Breakdown
SS=D: 5
SS=E: 2
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to follow physician's orders for wound care including cleansing wound after soiled dressing removal, hand hygiene, and glove changes during treatment (Resident #11). | SS=D |
| Failed to ensure timely reorder of Albuterol inhaler and follow physician's orders for daily weights and notification of significant weight gains (Resident #9). | SS=D |
| Failed to provide appropriate incontinence care to prevent cross contamination and infection (Residents #11 and #12). | SS=D |
| Failed to ensure call light within reach for residents (Residents #11 and #12). | SS=D |
| Failed to ensure treatment and medication carts kept locked when unattended by staff. | SS=E |
| Failed to have an effective quality assurance program to address repeated deficiencies and improve quality of care. | SS=F |
| Failed to ensure infection prevention and control practices including hand hygiene, glove use, and proper wound care procedures. Failed to wear gloves during blood sugar check (Resident #7). | SS=E |
Report Facts
Resident census: 57
Weight gains: 14.7
Weight gains: 13.8
Medication reorder threshold: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in wound care deficiency and medication reorder issues |
| Staff B | Licensed Practical Nurse | Named in medication reorder and inhaler order issues |
| Staff C | Certified Nursing Assistant | Named in incontinence care deficiency |
| Staff F | Certified Nursing Assistant | Named in incontinence care deficiency |
| Staff I | Assistant Director of Nursing | Provided expectations on infection control and call light accessibility |
| Staff E | Registered Nurse | Provided information on medication cart locking issues |
| Corporate Nurse | Provided information on medication reorder and inhaler orders | |
| Infection Preventionist | Provided infection control expectations and observations |
Inspection Report
Census: 73
Deficiencies: 11
Oct 25, 2023
Visit Reason
The inspection was conducted based on complaint investigations and facility reported incidents related to resident rights, notification of changes, abuse allegations, and quality of care concerns.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to notify physicians timely of changes in condition, failure to report and investigate abuse allegations promptly, failure to provide care according to professional standards including missed appointments and medication administration errors, failure to provide adequate bathing and personal care, failure to assess and manage wounds leading to severe complications, failure to provide adequate supervision to prevent accidents and elopement, insufficient nursing staff to meet resident needs, failure to complete annual nurse aide performance reviews, and failure to secure medication carts properly.
Complaint Details
The visit was complaint-related, triggered by multiple substantiated complaints and facility reported incidents involving resident rights violations, abuse allegations, failure to notify changes, and quality of care concerns.
Severity Breakdown
SS=D: 5
SS=J: 2
SS=E: 3
SS=G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to treat a resident with respect and dignity, including improper repositioning causing distress. | SS=D |
| Failure to notify physician timely of urinary analysis results and changes in resident condition. | SS=D |
| Failure to report alleged abuse immediately and to appropriate authorities within required timeframes. | SS=D |
| Failure to thoroughly investigate abuse allegations and separate alleged abuser from victim. | SS=J |
| Failure to provide care and services according to accepted professional standards including missed follow-up appointments and incorrect medication administration timing. | SS=D |
| Failure to provide two baths per week as directed for dependent residents. | SS=E |
| Failure to provide ongoing assessment and intervention for a resident with an unstageable wound leading to severe infection and amputation. | SS=J |
| Failure to ensure resident environment is free of accident hazards and provide adequate supervision to prevent accidents and elopement. | SS=G |
| Failure to provide sufficient nursing staff to meet resident care needs including bathing. | SS=E |
| Failure to complete annual nurse aide performance evaluation. | SS=D |
| Failure to ensure medication carts were locked and secured when unattended. | SS=E |
Report Facts
Deficiencies cited: 11
Resident census: 73
Staff N work shifts: 2
Baths missed: 9
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Certified Nursing Assistant | Named in abuse allegation and failure to follow proper repositioning and reporting procedures. |
| Staff M | Certified Nursing Assistant | Named as reporter of abuse allegation against Staff N. |
| Staff A | Certified Nursing Assistant | Named in fall incident resulting in resident injury due to failure to use gait belt. |
| Staff B | Certified Nursing Assistant | Named in failure to provide 1:1 supervision leading to resident elopement. |
| Staff G | Licensed Practical Nurse | Named in medication cart left unlocked. |
| Staff L | Licensed Practical Nurse | Named in medication cart left unlocked and medication administration errors. |
| Staff F | Licensed Practical Nurse | Named in medication cart left unlocked and failure to provide 1:1 supervision. |
| Staff H | Registered Nurse | Named in failure to assure follow-up appointments and medication administration. |
| Staff I | Licensed Practical Nurse | Named in failure to complete wound assessments. |
| Staff J | Assistant Director of Nursing | Named in abuse investigation and reporting. |
| Staff C | Registered Nurse | Named in fall incident investigation. |
| Staff E | Licensed Practical Nurse | Named in failure to provide 1:1 supervision. |
| Staff K | Certified Medication Aide | Named in failure to provide baths and medication administration. |
Inspection Report
Routine
Census: 79
Deficiencies: 43
Aug 16, 2023
Visit Reason
Routine annual recertification and complaint investigation survey conducted to assess compliance with resident rights, care, safety, and regulatory requirements.
Findings
The facility was found deficient in multiple areas including resident rights violations, failure to address resident grievances, mismanagement of personal funds, inaccurate advance directive documentation, failure to notify family and physician of changes, unsafe environment, abuse and neglect issues, medication errors, infection control lapses, and inadequate staffing.
Complaint Details
Multiple residents reported staff being rough during cares and disrespectful behavior by staff. Several staff members were suspended and terminated following investigations. The facility failed to report and investigate all allegations of abuse timely and thoroughly. Resident #276 reported a staff member slapped her on the back and was rough. Resident #32 reported staff were rude and condescending. Resident #7 reported night staff were rude and rough. Resident #65 reported staff were rough when changing him. Resident #24 reported staff were rough and hurt her. The facility conducted interviews with residents and family members and provided education to staff on abuse prevention and reporting.
Severity Breakdown
SS=E: 18
SS=D: 14
SS=L: 3
SS=G: 1
Deficiencies (43)
| Description | Severity |
|---|---|
| Failure to treat residents with respect and dignity; staff spoke in derogatory manner and confined residents without clinical indication. | SS=E |
| Failure to act on grievances voiced in Resident Council meetings for multiple months. | SS=E |
| Failure to provide ready access to residents' personal funds managed by the facility. | SS=D |
| Failure to maintain accurate accounting records for residents' personal funds. | SS=D |
| Failure to accurately document advance directives for a resident. | SS=D |
| Failure to notify physician and family of resident's change in condition. | SS=D |
| Failure to maintain a safe, clean, comfortable, and homelike environment; stained carpets and damaged flooring. | SS=E |
| Failure to provide an environment free from physical abuse; multiple residents reported staff roughness and disrespect. | SS=L |
| Failure to develop and implement written policies ensuring dependent adult abuse training and background checks for staff. | SS=D |
| Failure to report all allegations of abuse to the State Agency within required timeframes. | SS=L |
| Failure to thoroughly investigate all allegations of abuse and separate alleged perpetrators from residents. | SS=L |
| Failure to provide bed hold notice to resident or representative upon transfer to hospital. | SS=D |
| Failure to ensure accuracy of Minimum Data Set assessments reflecting resident status and diagnoses. | SS=D |
| Failure to coordinate PASARR evaluations timely and accurately. | SS=D |
| Failure to develop and implement comprehensive care plans reflecting resident needs including hospice, communication, and fall prevention. | SS=D |
| Failure to provide services consistent with professional standards including following physician orders and ensuring dialysis care. | SS=D |
| Failure to provide sufficient nursing staff to ensure timely call light response and resident assistance. | SS=E |
| Failure to provide necessary Activities of Daily Living assistance including bathing, positioning, oral care, and incontinence care. | SS=E |
| Failure to maintain food temperatures and serve palatable meals at appropriate temperatures. | SS=D |
| Failure to ensure food safety by serving expired food and failing to label and date opened food items. | SS=D |
| Failure to verify staff licensure prior to hire. | SS=D |
| Failure to follow infection control practices including disinfecting glucometers and safe medication administration. | SS=D |
| Failure to maintain a qualified infection preventionist with current certification. | SS=D |
| Failure to ensure tuberculosis testing for newly hired staff prior to employment. | SS=D |
| Failure to provide adequate nutrition and hydration; failure to document supplement intake and weights. | SS=D |
| Failure to provide respiratory care including availability of portable oxygen tanks. | SS=D |
| Failure to provide adequate pain management including timely medication administration and reassessment. | SS=D |
| Failure to ensure dialysis care including pre and post assessments and transportation. | SS=D |
| Failure to update and revise care plans timely to reflect resident needs including hospice, communication, and fall prevention. | SS=D |
| Failure to follow physician orders including medication administration and lab monitoring. | SS=D |
| Failure to implement timely discharge planning and notify family of resident decisions. | SS=D |
| Failure to provide adequate Activities of Daily Living assistance including bathing, toileting, and incontinence care. | SS=E |
| Failure to provide quality care including timely assessment and intervention for change in condition and pressure ulcer prevention and treatment. | SS=G |
| Failure to analyze falls and implement interventions to prevent further falls. | SS=D |
| Failure to provide bowel and bladder incontinence care in a timely manner. | SS=D |
| Failure to ensure medication availability and accurate controlled substance reconciliation. | SS=E |
| Failure to ensure psychotropic medications are administered only for diagnosed conditions and PRN orders have appropriate rationale and duration. | SS=D |
| Failure to maintain food palatability and temperature during meal service. | SS=D |
| Failure to ensure food safety by discarding expired food and labeling opened food items. | SS=D |
| Failure to verify staff licensure prior to hire. | SS=D |
| Failure to follow infection control practices including disinfecting glucometers and safe medication administration. | SS=D |
| Failure to maintain a qualified infection preventionist with current certification. | SS=D |
| Failure to ensure tuberculosis testing for newly hired staff prior to employment. | SS=D |
Report Facts
Medication error rate: 10.71
Residents interviewed for abuse: 10
Residents interviewed for abuse: 10
Expired food items found: 38
Call light response time: 15
Falls in 3 months: 25
Medication administration errors: 11
Missed dialysis treatments: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Certified Nursing Assistant | Named in abuse and roughness allegations, suspended and terminated |
| Staff Q | Certified Nursing Assistant | Named in abuse and roughness allegations, suspended and terminated |
| Staff FF | Certified Nursing Assistant | Named in abuse and roughness allegations, suspended and terminated |
| Staff HH | Nurse | Named in abuse allegations, terminated |
| Staff Z | Certified Nursing Assistant | Named in disrespectful behavior to resident, suspended and terminated |
| Staff B | Licensed Practical Nurse | Named in medication administration and licensure verification issues |
| Staff JJ | Registered Nurse | Named in TB testing deficiency and abuse investigation |
| Staff A | Certified Medication Aide | Named in medication administration error and infection control lapses |
| Staff I | Licensed Practical Nurse | Named in infection control lapses |
| Staff E | Licensed Practical Nurse | Named in wound care and abuse investigation |
| Staff R | Certified Nurse Aide | Named in incontinence care and abuse investigation |
| Staff LL | Certified Nurse Aide | Named in incontinence care lapses |
| Staff M | Certified Nurse Aide | Named in incontinence care lapses |
| Staff MM | Certified Nurse Aide | Named in incontinence care lapses |
| Staff S | Nurse Practitioner | Named in psychotropic medication management and wound care |
| Staff W | Licensed Practical Nurse | Named in abuse investigation and notification lapses |
Inspection Report
Deficiencies: 0
Apr 28, 2023
Visit Reason
The inspection was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The nursing home was found to be in compliance with the applicable federal requirements as of the inspection date.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 7
Apr 4, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and to investigate multiple complaints and facility-reported incidents from February 14, 2023 to April 4, 2023.
Findings
The facility was found in compliance with COVID-19 practices but had multiple deficiencies including failure to treat residents with dignity, failure to maintain a safe and clean environment, failure to properly document and manage resident transfers and discharges, failure to provide adequate ADL care including showers, failure to follow professional standards for medication administration, and failure to prevent and treat pressure ulcers.
Complaint Details
The visit was complaint-related involving multiple substantiated complaints and facility-reported incidents including issues with resident dignity, discharge procedures, and care quality.
Severity Breakdown
SS=D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to treat residents with dignity, including pulling a resident backwards in a wheelchair and calling residents by names of endearment without care plan direction. | SS=D |
| Facility failed to keep a resident's room sanitary and orderly, with clutter covering most surfaces and floor space. | SS=D |
| Facility failed to provide proper documentation and follow discharge regulations for a resident who left against medical advice and was not permitted to return. | SS=D |
| Facility failed to provide twice weekly showers to a resident requiring extensive assistance. | SS=D |
| Facility failed to follow professional standards of practice for medication administration, including leaving treatment cream on bedside table and administering eye drops to both eyes instead of one. | SS=D |
| Facility failed to provide assessment and intervention to prevent pressure ulcer development, resulting in a Stage 3 pressure ulcer and hematoma not assessed or treated timely. | SS=D |
| Facility failed to answer call lights in a timely manner, with a call light observed on for over 50 minutes without response. | SS=D |
Report Facts
Total Residents: 83
Deficiencies cited: 7
Resident #17 showers: 1
Pressure ulcer size: 5.5
Pressure ulcer size: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Observed pulling resident backwards in wheelchair and calling residents by names of endearment |
| Staff H | Registered Nurse (RN) | Administered treatment and called resident by inappropriate name |
| Staff F | Nurse Supervisor, Licensed Practical Nurse (LPN) | Reviewed wound care and described resident agitation and AMA process |
| Staff J | Licensed Practical Nurse (LPN) | Reviewed wound areas and medication administration |
| Staff I | Licensed Practical Nurse (LPN) | Administered eye drops to wrong eye and reported error |
| Staff G | Nursing Supervisor, Licensed Practical Nurse (LPN) | Discussed resident wanting to leave and AMA process |
| Staff E | Certified Nurse Aide (CNA) | Responded to call light after long delay |
| Staff D | Certified Nurse Aide (CNA) | Assisted resident after call light delay |
| Staff K | Occupational Therapist (OT) | Notified nursing of skin integrity concerns |
| Administrator | Acknowledged issues with resident dignity, discharge, and call light response | |
| Director of Nursing (DON) | Acknowledged call light response issues and reviewed wound care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2022
Visit Reason
A complaint investigation was conducted for complaints #104862-C, #107051-C, #107225-C, and #107472-C, as well as facility reported incidents #107216-I and #10748-I from September 13, 2022 to September 23, 2022.
Findings
The facility was found to be in substantial compliance with the applicable regulations.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 5, 2022
Visit Reason
The document is a plan of correction accepted following a survey and investigation ending May 31, 2022, to certify the facility in compliance effective August 5, 2022.
Findings
The facility submitted a credible allegation of compliance and plan of correction after the survey and investigation, resulting in certification of compliance effective August 5, 2022.
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 12
May 31, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of multiple complaints and a facility-reported incident.
Findings
The facility was found deficient in multiple areas including failure to ensure a homelike environment with clean bed linens, inadequate investigation of abuse allegations, failure to notify the Long Term Care Ombudsman of resident transfers, incomplete bed hold notices, inaccurate assessments, incomplete care plans, failure to provide restorative activities, insufficient nursing staff to provide timely assistance, unsanitary kitchen conditions, and failure to administer influenza vaccine to a resident.
Complaint Details
Complaints #97182-C and #98375-C were substantiated. Complaint #102364-C was substantiated without deficiency. Complaints #98822-C, #100258-C, and #101472-C were unsubstantiated. Facility-reported incident #102590-I was substantiated.
Severity Breakdown
Level B: 1
Level D: 9
Level E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to ensure a homelike environment by not providing clean bed linens and consistently making the bed for a resident with incontinence. | Level D |
| Failure to conduct a thorough investigation following a family concern related to medication administration for a resident. | Level D |
| Failure to notify the Long Term Care Ombudsman of resident transfers to hospital for three residents. | Level B |
| Failure to provide resident or representative notice of bed hold policy at time of hospital transfer for two residents. | Level D |
| Failure to submit a PASRR for a resident with newly diagnosed mental disorder. | Level D |
| Failure to develop and implement a baseline care plan within 48 hours of admission for a resident. | Level E |
| Failure to develop comprehensive care plans addressing psychotropic and pain medications for multiple residents. | Level D |
| Failure to ensure medication administration by licensed staff only, proper documentation, and proper disposal of refused medications for a resident. | Level D |
| Failure to provide restorative activities to maintain functional range of motion and prevent decline in activities of daily living for a resident. | Level D |
| Failure to ensure sufficient nursing staff to provide timely assistance to a resident requiring two-person assist. | Level D |
| Failure to maintain clean and sanitary kitchen conditions including sticky floors, carbon buildup on stove, and dirty microwave and steam table. | Level D |
| Failure to administer influenza vaccine to a resident who consented and lacked documentation of education or communication regarding vaccine administration. | Level D |
Report Facts
Complaints investigated: 6
Facility-reported incidents investigated: 1
Residents present: 69
Residents reviewed: 24
Residents reviewed for immunizations: 5
Residents reviewed for medication administration: 6
Residents reviewed for restorative activities: 6
Residents reviewed for care plans: 19
Residents reviewed for nursing staff assistance: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nurse Aide | Named in medication administration finding related to Resident #67 |
| Staff I | Registered Nurse | Named in medication administration finding related to Resident #67 |
| Staff H | Registered Nurse | Named in medication administration finding related to Resident #67 |
| Staff G | Licensed Practical Nurse | Named in medication administration finding related to Resident #67 |
| Staff E | Interim Director of Nursing | Named in medication administration finding related to Resident #67 |
| Staff D | Assistant Director of Nursing | Named in immunization and psychotropic medication monitoring findings |
| Staff J | Physical Therapist | Named in restorative activities finding related to Resident #10 |
| Staff B | Certified Medication Aide | Named in restorative activities finding |
Inspection Report
Renewal
Census: 52
Deficiencies: 3
Mar 16, 2021
Visit Reason
The inspection was a recertification survey conducted from 03/10/2021 to 03/16/2021 to assess compliance with federal regulations for Pine Acres Rehabilitation and Care Center LLC.
Findings
The facility was found deficient in documenting residents' wishes regarding resuscitation and advance directives for three of five residents reviewed, and failed to resubmit a Preadmission Screening and Resident Review (PASARR) after a change in diagnosis and medication for one resident. Additionally, the facility failed to submit timely veteran admissions information for two residents.
Deficiencies (3)
| Description |
|---|
| Failure to ensure adequate documentation of resident wishes for resuscitation and advance directives for three residents. |
| Failure to resubmit a Preadmission Screening and Resident Review (PASARR) after a change in diagnosis and medication for one resident. |
| Failure to submit veteran admissions information to the Iowa Department of Veteran Affairs within 30 days for two residents. |
Report Facts
Residents present: 52
Residents reviewed for advance directives: 5
Resident admissions reviewed for veteran status submission: 32
Residents with late veteran status submission: 2
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Feb 2, 2021
Visit Reason
The inspection was conducted due to investigation of Incident #95225-I and Complaint #93980-C between 1/25/21 and 2/2/21.
Findings
The facility failed to ensure adequate supervision to prevent elopement for one of three residents reviewed, resulting in Resident #1 being found outside the building without staff awareness. The facility's investigation confirmed the incident and identified deficiencies in supervision and alarm response.
Complaint Details
Incident #95225-I was substantiated. Complaint #93980-C was not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received adequate supervision to prevent elopement for 1 of 3 residents reviewed. | SS=D |
Report Facts
Resident census: 56
Residents reviewed: 3
Resident MDS assessment date: Nov 30, 2020
Wandering Assessment date: Oct 19, 2020
Elopement Incident Report date: Jan 21, 2021
Weekly Test of Door Alarm Systems date: Jan 14, 2021
Date of compliance: Feb 2, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Prepared Elopement Incident Report and documented nursing progress note |
| Staff B | Certified Nurse Aide (CNA) | Interviewed regarding resident supervision and elopement incident |
| Staff C | Certified Nurse Aide (CNA) | Interviewed regarding resident supervision and elopement incident |
| Staff D | Certified Nurse Aide (CNA) | Interviewed regarding resident supervision and elopement incident |
| Staff E | Screener | Interviewed regarding resident supervision and elopement incident |
| Staff F | Dietary Aide | Interviewed regarding resident supervision and elopement incident |
| Administrator | Interviewed and confirmed staff training and facility investigation findings | |
| Director of Nursing | Director of Nursing (DON) | Interviewed and confirmed staff training and facility investigation findings |
| Social Worker | Interviewed regarding resident elopement and wandering behavior |
Inspection Report
Routine
Census: 55
Deficiencies: 0
Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/28/2020 through 12/29/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Dec 9, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control during the survey conducted December 7-9, 2020.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Sep 17, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted in conjunction with investigation of complaint #93053-C and #92899-C on 9-16-20 thru 9-17-20.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Complaints #93053 and #92889 were not substantiated.
Complaint Details
Complaints #93053 and #92889 were investigated and found not substantiated.
Report Facts
Total residents: 65
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigation of complaint #89178-C and facility reported incidents #92265-I and #92768-I on August 17-20, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Investigation of complaint #89178-C and facility-reported incidents #92265-I and #92768-I were not substantiated.
Complaint Details
Investigation of complaint #89178-C and facility-reported incidents #92265-I and #92768-I were not substantiated.
Report Facts
Complaint number: 89178
Facility reported incident numbers: 92265
Facility reported incident numbers: 92768
Inspection Report
Routine
Census: 65
Deficiencies: 0
Jul 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 7/14/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Jun 18, 2020
Visit Reason
A focused COVID-19 infection survey was conducted in conjunction with investigation of complaints #89217-C and #90365-C from June 11-18, 2020. The investigation of complaint #89217-C resulted in deficiencies, while complaint #90365-C did not.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. However, a deficiency was cited for failure to include the resident or resident representative in the initial care plan process and failure to create an initial comprehensive care plan for 1 of 4 residents reviewed (Resident #4).
Complaint Details
Investigation of complaint #89217-C resulted in deficiencies; investigation of complaint #90365-C did not result in deficiencies.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to include the resident or resident representative in the initial care plan process and failure to create an initial comprehensive care plan for Resident #4. | Level D |
Report Facts
Total residents: 67
BIMS score: 14
Dates of care plan updates: Multiple dates from 1/20/20 to 5/5/20 noted for care plan updates for Resident #4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Responded regarding lack of initial comprehensive care plan for Resident #4 and described care plan update process |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 3
Jan 30, 2020
Visit Reason
Investigation of the facility's self-reported incidents and complaints related to abuse, neglect, and misappropriation of resident property.
Findings
The facility failed to investigate injuries of unknown origin including bruises and skin tears on residents, and failed to investigate an allegation of missing resident property. Additionally, the facility failed to report reasonable suspicion of a crime related to a missing resident's wedding ring and failed to follow care plan interventions for a resident with fragile skin.
Complaint Details
The investigation was triggered by complaints #88785-C and #87244-C, and self-reported incidents #88116-M and #88810-1. Complaint #87799-C was not substantiated.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to investigate injuries of unknown origin including bruises on 2 residents and skin tears on 1 resident, and failed to investigate an allegation of missing resident property for 1 resident. | SS=D |
| Failed to report reasonable suspicion of a crime when a resident's wedding ring was reported missing. | SS=D |
| Failed to follow care plan interventions to maintain the highest physical, mental and psychosocial well-being for a resident with fragile skin. | SS=D |
Report Facts
Census: 74
Skin tear measurement: 8
Skin tear measurement: 1
Bruise measurement: 4
Bruise measurement: 5
BIMS score: 7
Date of survey: Jan 30, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Nurse on duty who assessed bruises and was involved in incident reporting |
| Staff D | Certified Nursing Assistant (CNA) | Reported resident was agitated and combative, assisted with transfers |
| Staff E | Certified Nursing Assistant (CNA) | Involved in resident transfers and alleged to have slapped resident's leg |
| Director of Nursing (DON) | Director of Nursing | Responsible for staff education and investigation oversight |
| Staff C | Social Worker | Involved in searching for missing resident property and communicating with responsible party |
| Staff F | Certified Medication Aide (CMA) | Reported skin tears and bruises on resident to nurse |
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