Deficiency Records for Pine Creek Manor Skilled Nursing and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Pine Creek Manor Skilled Nursing and Rehab 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? |
|---|---|---|---|---|
| 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 | 2024-01-09 | 2024-02-19 | 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 | 2024-01-09 | 2024-02-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-09 | 2024-02-19 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-01-09 | 2024-02-19 | N |
| Post nurse staffing information every day. | Health | 2024-01-09 | 2024-02-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-09 | 2024-02-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-09 | 2024-02-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-10 | 2024-02-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-24 | 2023-09-28 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-19 | 2022-12-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-12-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-19 | 2022-12-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-19 | 2022-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-21 | 2022-11-28 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-21 | 2022-11-28 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-10-21 | 2022-11-28 | N |
| Keep all essential equipment working safely. | Health | 2022-10-21 | 2022-11-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-21 | 2022-11-28 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-21 | 2022-11-28 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-19 | 2022-11-28 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-02-11 | 2022-03-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-11 | 2022-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-11 | 2022-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-11 | 2022-03-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-11 | 2022-03-03 | 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 | 2022-02-11 | 2022-03-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-02 | 2021-09-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-02 | 2021-09-03 | N |
| Provide appropriate foot care. | Health | 2021-08-02 | 2021-09-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-08-02 | 2021-09-03 | 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 | 2021-08-02 | 2021-09-03 | 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 | 2021-08-02 | 2021-09-03 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-08-02 | 2021-09-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-02 | 2021-09-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-02 | 2021-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-02 | 2021-09-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-02 | 2021-09-03 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-27 | 2021-09-03 | 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 | 2021-07-27 | 2021-09-03 | 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 | 2021-07-27 | 2021-09-03 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-07-27 | 2021-09-03 | 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 | 2021-07-27 | 2021-09-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-27 | 2021-09-03 | N |
