A list of the most recent deficiencies for Pine Haven Home. 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 that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-30 | 2022-05-27 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-03-30 | 2022-05-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-30 | 2022-05-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-30 | 2022-05-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-03-30 | 2022-05-27 | 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 | 2022-03-30 | 2022-05-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-22 | 2020-01-13 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-10-22 | 2019-12-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-22 | 2019-12-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-22 | 2019-12-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-22 | 2019-12-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-10-22 | 2019-12-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-22 | 2019-12-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-22 | 2019-12-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-22 | 2019-12-06 | 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 | 2019-10-22 | 2019-12-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-22 | 2019-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-22 | 2019-12-06 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-07-25 | 2018-09-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-07-25 | 2018-09-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-25 | 2018-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-25 | 2018-09-07 | 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 | 2018-07-25 | 2018-09-07 | 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 | 2018-07-25 | 2018-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-25 | 2018-09-07 | N |
| Dispose of garbage and refuse properly. | Health | 2018-07-25 | 2018-09-07 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-07-25 | 2018-09-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-07-25 | 2018-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-25 | 2018-09-07 | N |
| Keep all essential equipment working safely. | Health | 2018-07-25 | 2018-09-07 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-07-25 | 2018-09-07 | N |
