Deficiency Records for Pine Grove Healthcare and Wellness Centre, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Pine Grove Healthcare and Wellness Centre, LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-10 | 2023-12-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-16 | 2023-04-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-11-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-12 | 2022-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-13 | 2022-10-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-31 | 2022-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-08 | 2021-10-05 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-07-15 | 2021-07-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-09 | 2021-05-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-09 | 2021-05-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-09 | 2021-05-18 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-09 | 2021-05-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-09 | 2021-05-18 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-04-09 | 2021-05-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-09 | 2021-05-18 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-04-09 | 2021-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-09 | 2021-05-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-09 | 2021-05-18 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-04-09 | 2021-05-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-07 | 2021-05-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-24 | 2019-12-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-10-24 | 2019-11-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-10-24 | 2019-11-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-10-24 | 2019-11-22 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-10-24 | 2019-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-24 | 2019-11-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-10-24 | 2019-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-24 | 2019-11-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-10-24 | 2019-11-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-09 | 2018-12-12 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-11-09 | 2018-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-09 | 2018-12-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-09 | 2018-12-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-09 | 2018-12-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-09 | 2018-12-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-11-09 | 2018-12-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-09 | 2018-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-09 | 2018-12-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-09 | 2018-12-12 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-11-09 | 2018-12-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-09 | 2018-12-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-09 | 2018-12-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-11-09 | 2018-12-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-08 | 2018-12-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-08 | 2018-12-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-11-08 | 2018-12-03 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-11-08 | 2018-12-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-08 | 2018-12-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-08 | 2018-12-03 | N |
