A list of the most recent deficiencies for Pine Lodge. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-15 | 2023-12-26 | N |
Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-15 | 2023-12-26 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-15 | 2023-12-26 | 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 | 2023-11-15 | 2023-12-26 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-15 | 2023-12-26 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-15 | 2023-12-26 | N |
Provide activities to meet all resident's needs. | Health | 2023-11-15 | 2023-12-26 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-15 | 2023-12-26 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-15 | 2023-12-26 | 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 | 2023-11-15 | 2023-12-26 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-15 | 2023-12-26 | 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 | 2023-11-15 | 2023-12-26 | 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 | 2023-11-15 | 2023-12-26 | N |
Post nurse staffing information every day. | Health | 2023-11-15 | 2023-12-26 | 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 | 2023-11-15 | 2023-12-26 | 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 | 2023-11-15 | 2023-12-26 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-15 | 2023-12-26 | N |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-11-15 | 2023-12-26 | N |
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 | 2023-11-15 | 2023-12-26 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-15 | 2023-12-26 | N |
Provide and implement an infection prevention and control program. | Health | 2023-11-15 | 2023-12-26 | N |
Implement a program that monitors antibiotic use. | Health | 2023-11-15 | 2023-12-26 | N |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-15 | 2023-12-26 | N |
Keep all essential equipment working safely. | Health | 2023-11-15 | 2023-12-26 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-15 | 2023-12-12 | 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 | 2023-11-15 | 2023-12-12 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-15 | 2023-12-12 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-15 | 2023-12-12 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-15 | 2023-12-12 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-15 | 2023-12-12 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-30 | 2023-10-01 | 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 | 2023-08-30 | 2023-10-01 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-30 | 2023-10-01 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-30 | 2023-10-01 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-30 | 2023-10-01 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-08-30 | 2023-10-01 | Y |
Report COVID19 data to residents and families. | Health | 2023-08-30 | 2023-10-01 | Y |
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 | 2022-06-29 | 2022-07-28 | 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 | 2022-06-29 | 2022-07-28 | N |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-29 | 2022-07-28 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-29 | 2022-07-28 | N |
Respond appropriately to all alleged violations. | Health | 2022-06-29 | 2022-07-28 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-29 | 2022-07-28 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-29 | 2022-07-28 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-29 | 2022-07-28 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-07-28 | 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 | 2022-06-29 | 2022-07-28 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-07-28 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-06-29 | 2022-07-28 | N |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-06-29 | 2022-07-28 | N |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-06-29 | 2022-07-28 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-29 | 2022-07-28 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-29 | 2022-07-28 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-07-28 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-06-29 | 2022-07-28 | N |
Provide and implement an infection prevention and control program. | Health | 2022-06-29 | 2022-07-28 | N |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-29 | 2022-07-28 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-29 | 2022-07-28 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-29 | 2022-07-28 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-05 | 2022-02-01 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-05 | 2022-01-15 | Y |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-03-18 | 2021-05-24 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-18 | 2021-05-24 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-18 | 2021-05-13 | 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 | 2021-03-18 | 2021-05-13 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-03-18 | 2021-05-13 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-03-18 | 2021-05-13 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-03-18 | 2021-04-13 | N |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-03-18 | 2021-04-13 | 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 | 2021-03-18 | 2021-04-13 | N |
Ensure each resident receives an accurate assessment. | Health | 2021-03-18 | 2021-04-13 | 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 | 2021-03-18 | 2021-04-13 | 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 | 2021-03-18 | 2021-04-13 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-18 | 2021-04-13 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-03-18 | 2021-04-13 | N |
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-03-18 | 2021-04-13 | 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 | 2021-03-18 | 2021-04-13 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-18 | 2021-04-13 | N |
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-03-18 | 2021-04-13 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2021-03-18 | 2021-04-13 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-18 | 2021-04-13 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-18 | 2021-04-13 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-18 | 2021-04-13 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-03-18 | 2021-04-13 | Y |