A list of the most recent deficiencies for Pines Nursing and Rehab. 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? |
|---|---|---|---|---|
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-09-28 | 2023-03-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-28 | 2023-03-18 | N |
| 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 | 2022-09-28 | 2023-03-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2023-03-18 | 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 | 2022-09-28 | 2023-03-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-28 | 2023-03-18 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-09-28 | 2023-03-03 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2022-09-28 | 2023-03-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-28 | 2023-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2023-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-28 | 2023-03-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-28 | 2023-03-03 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-09-28 | 2023-03-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-28 | 2023-03-03 | N |
| 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 | 2022-09-28 | 2023-03-03 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-09-28 | 2023-03-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-28 | 2023-03-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-09-28 | 2023-03-03 | N |
| Keep all essential equipment working safely. | Health | 2022-09-28 | 2023-03-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2023-03-03 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-28 | 2023-03-03 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-09-28 | 2023-03-03 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-28 | 2023-03-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-28 | 2023-03-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-28 | 2023-03-03 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-09-28 | 2023-03-03 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-09-28 | 2023-03-03 | Y |
| 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 | 2022-09-28 | 2023-03-03 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-09-28 | 2023-03-03 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-28 | 2023-03-03 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-28 | 2023-03-03 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-09-28 | 2023-03-03 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-09-28 | 2023-03-03 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-09-28 | 2023-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-28 | 2023-03-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-09-28 | 2023-03-03 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-28 | 2023-03-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-09-28 | 2023-03-03 | Y |
| Provide appropriate foot care. | Health | 2022-09-28 | 2023-03-03 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-09-28 | 2023-03-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-28 | 2023-03-03 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-04 | 2023-02-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-04 | 2023-02-24 | N |
| Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Fire Safety | 2022-10-04 | 2023-02-24 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-04 | 2023-02-24 | N |
| Meet other general requirements. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-04 | 2023-01-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-28 | 2022-11-27 | 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 | 2022-09-28 | 2022-11-27 | 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 | 2022-09-28 | 2022-11-27 | N |
| Post nurse staffing information every day. | Health | 2022-09-28 | 2022-11-27 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2022-09-28 | 2022-11-27 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-09-28 | 2022-11-27 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-09-28 | 2022-11-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-28 | 2022-11-27 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-28 | 2022-11-27 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-09-28 | 2022-11-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-28 | 2022-11-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-28 | 2022-11-27 | 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 | 2022-09-28 | 2022-11-27 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-09-28 | 2022-11-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-28 | 2022-11-27 | Y |
| 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 | 2022-09-28 | 2022-11-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-28 | 2022-11-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-28 | 2022-11-27 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-09-28 | 2022-11-27 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2022-09-28 | 2022-11-27 | 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 | 2022-09-28 | 2022-11-27 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-09-28 | 2022-11-27 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-09-28 | 2022-11-27 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-09-28 | 2022-11-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-28 | 2022-11-27 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-09-28 | 2022-11-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-28 | 2022-11-27 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-28 | 2022-11-27 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-28 | 2022-11-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-28 | 2022-11-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-28 | 2022-11-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-28 | 2022-11-27 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-09-28 | 2022-11-27 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-28 | 2022-11-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-28 | 2022-11-27 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-09-28 | 2022-11-27 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-09-28 | 2022-11-27 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-09-28 | 2022-11-20 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-05-20 | 2022-06-22 | 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 | 2022-05-20 | 2022-06-22 | Y |
| Post nurse staffing information every day. | Health | 2022-05-20 | 2022-06-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-20 | 2022-06-22 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-09 | 2022-05-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-09 | 2022-05-08 | 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 | 2022-03-09 | 2022-05-08 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-10-25 | 2018-12-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-10-25 | 2018-12-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-10-25 | 2018-12-01 | 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 | 2018-10-25 | 2018-12-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-25 | 2018-12-01 | N |
| 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 | 2018-10-25 | 2018-12-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-25 | 2018-12-01 | 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 | 2018-10-25 | 2018-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-25 | 2018-12-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-25 | 2018-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-25 | 2018-12-01 | 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 | 2018-10-25 | 2018-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-25 | 2018-12-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-25 | 2018-12-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-25 | 2018-12-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-25 | 2018-12-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-10-25 | 2018-12-01 | 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 | 2018-10-25 | 2018-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-25 | 2018-12-01 | 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 | 2018-10-25 | 2018-12-01 | N |
| Provide or obtain dental services for each resident. | Health | 2018-10-25 | 2018-12-01 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-10-25 | 2018-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-25 | 2018-12-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-25 | 2018-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-12-01 | N |
| Keep all essential equipment working safely. | Health | 2018-10-25 | 2018-12-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-10-25 | 2018-12-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-10-25 | 2018-10-25 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2017-07-21 | 2017-10-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-07-28 | 2017-09-07 | N |
| Provide housekeeping and maintenance services. | Health | 2017-07-28 | 2017-09-07 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-07-28 | 2017-09-07 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-07-28 | 2017-09-07 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-28 | 2017-09-07 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-07-28 | 2017-09-07 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-28 | 2017-09-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-21 | 2017-08-31 | N |
