Deficiency Records for Pine Acres Rehabilitation and Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Pine Acres Rehabilitation and Care Center. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-20 | 2024-01-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-20 | 2024-01-25 | Y |
| 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 | 2023-12-20 | 2024-01-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-20 | 2024-01-25 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-20 | 2024-01-25 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-12-20 | 2024-01-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-20 | 2024-01-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-25 | 2024-01-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-25 | 2024-01-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-25 | 2024-01-25 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-25 | 2024-01-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-16 | 2024-01-25 | 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 | 2023-08-16 | 2024-01-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-16 | 2024-01-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-16 | 2024-01-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-16 | 2024-01-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-25 | 2023-11-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-25 | 2023-11-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-25 | 2023-11-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-25 | 2023-11-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-25 | 2023-11-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-25 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-10-25 | 2023-11-25 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-08-16 | 2023-10-08 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-08-16 | 2023-10-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-16 | 2023-10-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-16 | 2023-10-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-16 | 2023-10-08 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-16 | 2023-10-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-16 | 2023-10-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-16 | 2023-10-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-16 | 2023-10-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-16 | 2023-10-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-16 | 2023-10-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-16 | 2023-10-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-16 | 2023-10-08 | 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 | 2023-08-16 | 2023-10-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-16 | 2023-10-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-16 | 2023-10-08 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-08-16 | 2023-10-08 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-08-16 | 2023-10-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-16 | 2023-10-08 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-08-16 | 2023-10-08 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-08-16 | 2023-10-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-16 | 2023-10-08 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-16 | 2023-10-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-08-16 | 2023-10-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-16 | 2023-10-08 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-16 | 2023-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-16 | 2023-10-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-16 | 2023-10-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-16 | 2023-10-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-16 | 2023-10-08 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-16 | 2023-10-08 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-24 | 2023-08-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-24 | 2023-08-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-24 | 2023-08-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-24 | 2023-08-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-04 | 2023-04-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-04 | 2023-04-28 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-04-04 | 2023-04-28 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-04-04 | 2023-04-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-04 | 2023-04-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-04 | 2023-04-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-04 | 2023-04-28 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-04 | 2023-04-28 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-05-31 | 2022-08-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-31 | 2022-08-05 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-05-31 | 2022-08-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-31 | 2022-08-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-31 | 2022-08-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-31 | 2022-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-31 | 2022-08-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-05-31 | 2022-08-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-31 | 2022-08-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-31 | 2022-08-05 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-31 | 2022-08-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-31 | 2022-08-05 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-31 | 2022-08-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-31 | 2022-08-05 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-25 | 2022-06-16 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-25 | 2022-06-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-25 | 2022-06-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-25 | 2022-06-03 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-05-25 | 2022-06-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-25 | 2022-06-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-05-25 | 2022-06-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-25 | 2022-06-01 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-25 | 2022-05-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-25 | 2022-05-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-05-25 | 2022-05-25 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-03-16 | 2021-04-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-03-16 | 2021-04-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-16 | 2021-04-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-03-16 | 2021-03-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-16 | 2021-03-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-03-16 | 2021-03-25 | N |
