Inspection Report
Census: 58
Capacity: 72
Deficiencies: 0
Jan 7, 2025
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 58
License Capacity: 72
Secured Dementia Care Unit Capacity: 24
Residents Served in Secured Dementia Care Unit: 21
Total Daily Staff: 84
Waking Staff: 63
Inspection Report
Follow-Up
Census: 54
Capacity: 72
Deficiencies: 2
Apr 2, 2024
Visit Reason
The inspection visit was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a medication administration error where a resident received a double dose due to failure to document administration on the Medication Administration Record (MAR). The facility took corrective actions including staff retraining and monitoring.
Deficiencies (2)
| Description |
|---|
| Failure to document medication administration on the MAR resulting in a resident receiving a double dose of medication. |
| Failure to follow prescriber's orders due to the medication error caused by missed documentation. |
Report Facts
License Capacity: 72
Residents Served: 54
Secured Dementia Care Unit Capacity: 24
Residents Served in Dementia Unit: 23
Hospice Residents: 2
Residents with Mobility Need: 23
Total Daily Staff: 77
Waking Staff: 58
Inspection Report
Renewal
Census: 52
Capacity: 72
Deficiencies: 5
Nov 15, 2023
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for THE PINES AT CLARKS SUMMIT.
Findings
The submitted plan of correction was determined to be fully implemented. Several deficiencies were identified and corrected, including failure to report incidents within 24 hours, missing refrigerator/freezer thermometers, delayed annual fire safety inspection, missing posted menus, and expired medications found in the medication cart.
Deficiencies (5)
| Description |
|---|
| Failure to report two resident fall incidents to the Department of Human Services within 24 hours as required. |
| Missing thermometers in refrigerators located in the Evergreen Secured Unit medication room and second floor medication room. |
| Annual fire safety inspection and supervised fire drill were delayed and conducted after the required deadline due to severe flooding and scheduling issues. |
| Resident menus were not posted for the present and upcoming weeks in the Evergreen Secured Unit at the time of inspection. |
| Expired medication (Vitamin D) found in medication cart with expiration date September 2023. |
Report Facts
License Capacity: 72
Residents Served: 52
Secured Dementia Care Unit Capacity: 24
Residents Served in Secured Dementia Care Unit: 22
Total Daily Staff: 74
Waking Staff: 56
Residents with Mobility Need: 22
Inspection Report
Complaint Investigation
Census: 64
Capacity: 72
Deficiencies: 0
Mar 17, 2023
Visit Reason
The inspection was conducted as a complaint and incident investigation during an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint and incident, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 64
License Capacity: 72
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 24
Current Hospice Residents: 3
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 5
Residents with Mobility Need: 24
Residents with Physical Disability: 1
Inspection Report
Renewal
Census: 43
Capacity: 72
Deficiencies: 10
Oct 13, 2021
Visit Reason
The inspection was conducted as a renewal inspection of the facility license for THE PINES AT CLARKS SUMMIT.
Findings
The inspection identified multiple deficiencies including unsigned resident contracts, missing emergency phone numbers, improper food storage, incomplete medical evaluations, presence of discontinued medications, unlabeled medications, uncalibrated glucometers, medication record discrepancies, and incomplete resident records. All deficiencies had plans of correction that were accepted and implemented.
Deficiencies (10)
| Description |
|---|
| The resident-home contract for resident #1 was not signed by the resident. |
| Telephone numbers required by regulation were not posted by the phone located in room #106. |
| A half full bag of chicken pieces was located in the main freezer; the bag was opened and unsealed. |
| Outdated or unlabeled food items without dates were found in the main kitchen freezer. |
| Resident #2's medical evaluation did not include the physician's license number; Resident #3's medical evaluation did not indicate weight. |
| Discontinued medications for residents #7 and #9 were found in the medication cart. |
| An unopened box of medication in the medication cart was not labeled with the resident's name. |
| Resident #5 and #6's glucometers were not calibrated to the correct time; PRN medications for residents #7 and #8 were missing from the medication cart. |
| Resident #10's controlled substance log sheet did not match the medication administration record and medication card. |
| Resident #10's record did not include religion information. |
Report Facts
License Capacity: 72
Residents Served: 43
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 11
Hospice Residents: 1
Total Daily Staff: 54
Waking Staff: 41
Residents Age 60 or Older: 43
Residents with Mobility Need: 11
Notice
Capacity: 72
Deficiencies: 0
Sep 7, 2021
Visit Reason
This document serves as a renewal notification and license issuance for The Pines at Clarks Summit Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Maximum capacity: 72
Secure Dementia Care Unit capacity: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report
Plan of Correction
Census: 44
Capacity: 72
Deficiencies: 1
Aug 19, 2021
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 08/19/2021 to review the submitted plan of correction related to an incident involving medication storage and accountability.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing a missing Diazepam pill discovered during a shift change. The investigation was unable to determine the cause of the missing medication, but corrective actions including staff training and monitoring of medication count verification forms were completed.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all staff signed the shift-to-shift Narcotic Count Verification forms as required, resulting in a missing Diazepam pill. |
Report Facts
License Capacity: 72
Residents Served: 44
Secured Dementia Care Unit Capacity: 24
Secured Dementia Care Unit Residents Served: 11
Resident Support Staff: 0
Total Daily Staff: 57
Waking Staff: 43
Residents Age 60 or Older: 44
Residents with Mobility Need: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michele Moskalczyk | Signed the letter confirming full implementation of plan of correction | |
| General Manger | Re-reviewed signature policy with all Med Techs and Nurses after missing medication incident | |
| Director of Wellness | Responsible for monitoring missing signatures daily and ensuring policy compliance | |
| Administrator/Designee | Responsible for monitoring ongoing compliance with medication storage policy |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 72
Deficiencies: 1
May 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of abuse involving direct care staff members at the facility.
Findings
The investigation found no physical or emotional evidence of abuse, and the resident's statements were inconsistent and unreliable. However, the facility failed to implement a required plan of supervision for the staff involved, resulting in a violation.
Complaint Details
Resident #1 alleged abuse by two direct care staff members on 5/9/21. The facility did not implement a plan of supervision as required. The investigation included interviews, physical examination of the resident, and contact with the resident's representative, Area Agency on Aging, police, and Bureau of Human Service Licensing. No evidence of abuse was found, but the lack of supervision plan was a violation.
Deficiencies (1)
| Description |
|---|
| Failure to develop and implement a plan of supervision or suspend staff involved in an alleged resident abuse incident. |
Report Facts
Residents Served: 39
License Capacity: 72
Residents Served in Secured Dementia Care Unit: 9
Capacity of Secured Dementia Care Unit: 24
Residents Age 60 or Older: 39
Residents with Mobility Need: 14
Residents with Physical Disability: 1
Current Hospice Residents: 1
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