Inspection Report Summary
The most recent inspection on December 18, 2025, found the facility in substantial compliance with all previously cited deficiencies corrected. Earlier inspections showed a pattern of deficiencies primarily related to quality of care, medication management, infection control, staffing levels, and resident supervision, with several substantiated complaints confirming these issues. Notable events included substantiated complaints involving medication errors that led to a fentanyl overdose and hospitalization, as well as incidents of inadequate supervision resulting in resident falls and elopement with injury; an Immediate Jeopardy was identified and later removed in late 2024. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, as recent re-inspections verified correction of deficiencies and substantial compliance was maintained at the latest review.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
38.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
780% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
85 residents
Based on a November 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 18, 2025
Visit Reason
A revisit of the surveys ending October 22, 2025 and November 4, 2025 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 9, 2025.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely assessment and intervention for residents, failure to notify providers about medication orders, and medication errors related to fentanyl patch administration.
Complaint Details
The complaint investigation found substantiated failures including delayed assessment and intervention for residents, failure to notify providers about medication orders, and medication administration errors involving fentanyl patches.
Findings
The facility failed to provide timely assessment and intervention for two residents, resulting in hospitalization for sepsis in one case and failure to notify the provider about psychotropic medication orders in another. Additionally, the facility failed to follow physician orders to remove an old fentanyl patch before applying a new one, leading to a fentanyl overdose and hospitalization.
Deficiencies (2)
Failure to provide timely assessment and intervention for Resident #1 and Resident #8, including failure to respond to change in condition and failure to notify provider about psychotropic medication order review.
Failure to follow physician orders to remove old fentanyl patch prior to applying a new patch for Resident #3.
Report Facts
Census: 85
Deficiencies cited: 2
Fentanyl patch dosage: 25
Ammonia levels: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Advanced Registered Nurse Practitioner (ARNP) | Assessed Resident #1 and Resident #3, involved in hospital transfer and interviews |
| Staff C | Licensed Practical Nurse (LPN) | Involved in care and medication administration for Resident #1 and Resident #3 |
| Staff F | Registered Nurse (RN) | Staff agency nurse who assessed Resident #1 and recommended hospital transfer |
| Staff G | Registered Nurse (RN) | Assisted in hospital transfer of Resident #1 |
| Staff H | Licensed Practical Nurse (LPN) | Entered medication orders for Resident #8 |
| Staff I | Registered Nurse (RN), former Director of Nursing | Discussed medication issues for Resident #8 |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Date: Nov 25, 2025
Visit Reason
The inspection was conducted as a result of complaints #2654183-C, #2654729-C, and #2657936-C, investigating quality of care issues at Pine Acres Rehabilitation and Care Center between October 29, 2025 and November 4, 2025.
Complaint Details
Complaints #2654183-C, #2654729-C, and #2657936-C were substantiated resulting in deficiencies related to quality of care and medication errors.
Findings
The facility failed to provide timely assessment and intervention for 2 of 3 residents reviewed, including failure to respond to changes in condition and failure to notify providers timely. Additionally, the facility failed to provide treatments as ordered by a physician for 1 of 3 residents, resulting in medication errors and improper wound care.
Deficiencies (2)
Failure to provide timely assessment and intervention for residents, including failure to respond to changes in condition and failure to notify providers.
Failure to provide treatments as ordered by a physician, including medication errors and improper wound care.
Report Facts
Census: 85
Complaints investigated: 3
Residents reviewed for assessment: 3
Residents with medication/treatment errors: 1
Residents with delayed assessment/intervention: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Medication Aide (CMA) | Stated medication administration details for Resident #1 |
| Staff B | Certified Nurse Aide (CNA) | Reported Resident #1 condition and care details |
| Staff C | Licensed Practical Nurse (LPN) | Instructed care for Resident #1 and reported observations |
| Staff F | Registered Nurse (RN) | Observed Resident #1 condition and reported concerns |
| Staff G | Registered Nurse (RN) | Responded to Resident #1 emergency and hospital transfer |
| Staff H | Licensed Practical Nurse (LPN) | Entered medication orders and confirmed medication administration process |
| Staff J | Licensed Practical Nurse (LPN) | Described medication administration verification process |
| Regional Director of Operations | Acknowledged medication error and expectations for correction | |
| ARNP | Advanced Registered Nurse Practitioner | Provided documentation and clinical input regarding Resident #1 |
| DON | Director of Nursing | Reviewed medication orders and participated in corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 25, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #2628715-C, #2628758-C, and #2631306-C from October 20 to October 22, 2025, focusing on medication administration and resident safety.
Complaint Details
The deficiency resulted from investigation of complaints #2628715-C, #2628758-C, and #2631306-C. The complaint related to medication errors was substantiated as evidenced by clinical record review, staff interviews, and resident condition.
Findings
The facility failed to ensure residents were free of significant medication errors, specifically related to the improper removal and application of fentanyl patches for Resident #3, leading to a fentanyl overdose and hospitalization. Multiple staff interviews and record reviews confirmed lapses in medication management and documentation.
Deficiencies (1)
Failure to follow physician orders to remove a fentanyl patch prior to applying a new patch for Resident #3, resulting in a medication error and fentanyl overdose.
Report Facts
Deficiency correction date: Dec 9, 2025
Fentanyl patch dosage: 25
Dates of complaint investigation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Advanced Registered Nurse Practitioner (ARNP) | Assessed Resident #3 and noted lethargy and confusion; involved in resident's hospital transfer |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding fentanyl patch application and disposal procedures |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 22, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction following acceptance of credible allegation of substantial compliance and Plan of Correction.
Findings
The facility will be certified in compliance effective September 19, 2025, based on acceptance of credible allegation of substantial compliance and Plan of Correction.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Report Facts
Certification effective date: Sep 19, 2025
Inspection Report
Routine
Census: 79
Deficiencies: 4
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding maintaining a safe, clean, and comfortable environment, appropriate incontinence care, adequate nursing staff, and infection prevention and control practices.
Findings
The facility failed to maintain a safe and homelike environment with issues such as stained carpets, peeling paint, and water damage. Incontinence care was inadequate for some residents, nursing staff response to call lights was delayed, and infection control practices were not properly followed, including improper catheter care and lack of PPE availability.
Deficiencies (4)
Failed to maintain a safe, clean, comfortable and homelike environment, including stained carpets, peeling paint, water leaks, and soiled wheelchairs.
Failed to provide appropriate incontinence care for one resident, not cleansing all required areas during care.
Failed to provide enough nursing staff to meet residents' needs and timely respond to call lights for 5 residents.
Failed to maintain infection prevention and control practices including improper hand hygiene during dining, improper catheter care, and lack of PPE availability.
Report Facts
Census: 79
Residents affected: 5
Residents affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Involved in incontinence care and catheter care deficiencies |
| Staff B | Certified Nursing Assistant (CNA) | Observed failing to perform hand hygiene during dining assistance |
| Staff C | Certified Nursing Assistant (CNA) | Involved in incontinence care and catheter care deficiencies |
| Staff D | Certified Nursing Assistant (CNA) | Observed placing catheter drainage container on carpeted floor |
| Staff E | Certified Nursing Assistant (CNA) | Observed improper catheter drainage technique |
| Staff F | Certified Nursing Assistant (CNA) | Assisted in catheter care |
| Staff G | Registered Nurse (RN) | Reported lack of PPE gowns and restocked PPE bins |
| Director of Nursing | Director of Nursing (DON) | Provided statements on expectations for cleanliness, call light response, and infection control |
| Maintenance Director | Maintenance Director | Confirmed facility maintenance issues and carpet cleaning equipment status |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 4
Date: Aug 26, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#1757001-C, #2567676-C, #2582029-C) and facility reported incidents (#2591845-I and #2598449-I) from August 18 to August 26, 2025.
Complaint Details
The deficiencies resulted from investigations of complaints #1757001-C, #2567676-C, and #2582029-C, which were substantiated as evidenced by the cited deficiencies.
Findings
The facility was found deficient in maintaining a safe, clean, comfortable, and homelike environment, proper bowel and bladder incontinence care including catheter management, sufficient nursing staff, and infection prevention and control practices. Specific issues included stained carpet and ceiling tiles, inadequate cleaning, improper catheter care, delayed response to call lights, and failure to maintain infection control protocols.
Deficiencies (4)
Failure to maintain a safe, clean, comfortable, and homelike environment including stained carpet, peeling paint, dirty vents, and poor maintenance.
Failure to provide appropriate bowel and bladder incontinence care, including catheter care and perineal hygiene.
Insufficient nursing staff to assure resident safety and timely response to call lights.
Failure to establish and maintain an infection prevention and control program, including hand hygiene and catheter care.
Report Facts
Complaints investigated: 3
Facility reported incidents: 2
Residents census: 79
Residents reviewed for nursing staff deficiency: 5
Residents reviewed for incontinence care deficiency: 3
Residents reviewed for infection control deficiency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding wheelchair cleaning expectations and catheter care |
| Staff A | Certified Nursing Assistant (CNA) | Observed providing care including cleansing resident and handling catheter |
| Staff B | Certified Nursing Assistant (CNA) | Observed assisting residents during lunch and infection control practices |
| Staff C | Certified Nursing Assistant (CNA) | Observed providing perineal care and emptying catheter bag |
| Staff F | Certified Nursing Assistant (CNA) | Observed providing catheter care and infection control |
| Staff G | Registered Nurse (RN) | Interviewed regarding ostomy care and infection control |
| Maintenance Director | Maintenance Director | Interviewed about facility maintenance and cleaning practices |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 9, 2025
Visit Reason
The document reflects acceptance of a credible allegation of substantial compliance and the facility's Plan of Correction, leading to certification in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction submitted, resulting in certification effective July 9, 2025.
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 2
Date: Jun 9, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with regulatory requirements including care plans, accident hazards, supervision, medication management, infection control, and quality assurance processes.
Findings
The facility was found to have multiple repeated non-harm level deficiencies related to ensuring a safe environment free from accident hazards, adequate supervision, comprehensive and timely care plan development and revision, infection prevention and control, and quality assurance performance improvement (QAPI) processes. Specific incidents included inadequate supervision of residents during smoking and a resident leaving the facility without signing out. The facility had ongoing issues with care plan comprehensiveness and fall prevention.
Deficiencies (2)
Failed to ensure the resident's environment was free from hazards and each resident received adequate supervision to prevent accidents and ensure safety for 2 of 4 residents reviewed.
Failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies.
Report Facts
Residents Affected: 75
Deficiency citations: 4
Audit frequency: 12
Audit frequency: 6
Elopement drill duration: 34
Resident absence duration: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Social Services | Completed smoking assessment for Resident #75 and provided statements regarding supervision expectations |
| Staff H | Registered Nurse (RN) | Documented progress notes and interviewed regarding Resident #5 leaving the facility without signing out |
| Staff I | Registered Nurse (RN) | Completed BIMS and elopement assessments for Resident #5 and provided interview statements |
| Administrator | Recalled incident of Resident #5 leaving facility, described facility response and expectations for staff supervision |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 9
Date: Jun 9, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey to assess compliance with regulatory requirements including care planning, medication management, resident safety, infection control, and other quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to document resident hospital transfers and notifications, inaccurate completion of Minimum Data Set assessments, failure to submit updated PASRR evaluations, incomplete and inaccurate care plans, inadequate supervision and safety measures to prevent accidents, improper medication management, unsafe medication storage and labeling, and failure to maintain infection prevention and control practices. Repeat deficiencies from prior surveys were noted.
Deficiencies (9)
Failure to document a resident's transfer to the hospital, physician and family notification, and a bed hold for 1 of 3 residents reviewed (Resident #7).
Failure to accurately complete a Minimum Data Set (MDS) Assessment by not identifying a resident had a serious mental illness as considered by the state level II PASRR for 1 of 16 residents (Resident #34).
Failure to submit an updated PASRR evaluation for 1 of 4 residents reviewed with mental health diagnosis and medications (Resident #31).
Failure to develop and implement a comprehensive person-centered care plan for 1 of 20 residents reviewed (Resident #25), specifically lacking interventions and goals for toileting hygiene and assistance.
Failure to revise the comprehensive care plan to accurately reflect status change for 1 of 20 residents reviewed (Resident #48), specifically not indicating a fractured right clavicle and weight bearing as tolerated status.
Failure to ensure the resident's environment was free from hazards and provide adequate supervision to prevent accidents for 2 of 4 residents reviewed (Resident #75 and Resident #5).
Failure to ensure knowledge and techniques necessary to care for residents' medication management in a timely manner for 1 of 5 residents reviewed (Resident #31), including failure to clarify and implement pharmacist's recommendation for gradual dose reduction.
Failure to safely store and label resident's medications, including undated opened stock medications and medication cups with pills left in medication cart.
Failure to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, including improper hand hygiene by dietary and nursing staff, failure to clean shared equipment between resident use.
Report Facts
Residents affected: 75
Deficiency count: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Social Services | Interviewed regarding PASRR evaluations and smoking assessments |
| Staff G | Administration | Interviewed regarding PASRR resubmission and recertification |
| Staff A | Certified Nursing Assistant | Interviewed regarding care needs and toileting assistance for Resident #25 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan expectations, medication management, infection control, and supervision |
| Staff B | Certified Medication Aide | Observed medication cart handling and interviewed about medication timing |
| Staff E | Dietary Staff | Observed improper hand hygiene during meal service |
| Staff F | Certified Nursing Assistant | Observed improper hand hygiene and unsafe feeding practices |
| Staff C | Certified Nursing Assistant | Observed failure to clean shared transfer equipment |
| Staff H | Registered Nurse | Documented resident elopement and educated resident on sign-out protocol |
| Staff I | Registered Nurse | Completed elopement and cognitive assessments for resident |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 10
Date: Jun 9, 2025
Visit Reason
The inspection was a special focus recertification survey and investigation of complaints #128433-C and #128732-C conducted from June 6, 2025 to June 9, 2025. Complaint #128433-C resulted in a deficiency.
Complaint Details
Complaint #128433-C resulted in a deficiency. Complaint #128732-C did not result in a deficiency.
Findings
The facility was found deficient in multiple areas including discharge process documentation, accuracy and coordination of PASARR assessments, comprehensive care plan development and revision, accident hazards and supervision, medication management, medication labeling and storage, infection prevention and control, and quality assurance performance improvement (QAPI) program. Several deficiencies were repeat citations from prior surveys.
Deficiencies (10)
Failed to document a resident's transfer to the hospital, physician and family notification, and bed hold for 1 of 3 residents reviewed (Resident #7).
Failed to accurately complete a Minimum Data Set (MDS) Assessment by not identifying a resident had a serious mental illness as considered by the state level II PASARR for 1 of 16 residents (Resident #34).
Failed to submit an updated PASARR evaluation for 1 of 4 residents reviewed with mental health diagnosis and medications (Resident #31).
Failed to develop and implement a comprehensive person-centered care plan for 1 of 20 residents reviewed (Resident #25), specifically lacking toileting hygiene interventions and goals.
Failed to revise the comprehensive care plan to accurately reflect status of 1 of 20 residents reviewed (Resident #48) after a fall resulting in fractured clavicle and weight bearing as tolerated (WBAT) order.
Failed to ensure resident environment was free from hazards and provide adequate supervision to prevent accidents for 2 of 4 residents reviewed (Resident #75 and #5). Resident #75 smoked without supervision or wearing a smoking apron contrary to policy. Resident #5 left the facility without notifying staff or signing out.
Failed to ensure knowledge and techniques necessary to care for residents' medication management in a timely manner for 1 of 5 residents reviewed (Resident #31), including failure to process a gradual dose reduction order.
Failed to safely store and label resident's medications, including undated stock medications and medication cups left prepared on medication cart.
Failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Observed staff serving drinks and food without proper hand hygiene, cross contamination during meal service, and failure to clean shared resident-care equipment between uses.
Failed to maintain an effective QAPI program to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the current survey.
Report Facts
Deficiencies cited: 10
Resident census: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Aide | Named in medication storage and labeling deficiency for leaving undated medications on medication cart. |
| Staff E | Dietary Staff | Named in infection control deficiency for improper hand hygiene while serving drinks. |
| Staff F | Certified Nursing Assistant | Named in infection control deficiency for cross contamination during meal service. |
| Staff H | Registered Nurse | Named in accident supervision deficiency related to resident elopement incident. |
| Staff I | Registered Nurse | Named in accident supervision deficiency related to resident elopement incident. |
| Corporate Nurse | Interviewed regarding failure to document hospital transfer and bed hold for Resident #7. | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication management, infection control, care plan revisions, and resident supervision. |
| Staff D | Social Services | Interviewed regarding PASARR coordination and smoking assessments. |
| Staff G | Administration | Interviewed regarding PASARR coordination. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 29, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective May 29, 2025.
Inspection Report
Routine
Census: 65
Deficiencies: 2
Date: May 1, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to treatment and care of residents, including assessment and intervention for residents with central lines and behavioral health needs, specifically substance use disorder.
Findings
The facility failed to provide appropriate assessment, obtain orders, or follow up with physicians for a resident with a central line, and failed to ensure an effective behavioral health program for a resident with substance use disorder, including lack of staff training and insufficient care planning.
Deficiencies (2)
Failed to provide assessments, obtain orders, or follow up with physician on a resident with an identified central line, including lack of monitoring and care for the central line.
Failed to ensure behavioral health program effectiveness for a resident with substance use disorder, including lack of staff training, incomplete care plans, and inadequate interventions for substance use and overdose risk.
Report Facts
Census: 65
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Registered Nurse (RN) | Confirmed documentation and lack of orders for Resident #2's central line |
| Staff C | Registered Nurse (RN) | Removed Resident #2's central line as ordered |
| Staff A | Registered Nurse (RN) | Worked with Resident #1 during episodes of manic and erratic behavior |
| Staff B | Registered Nurse (RN) | Observed Resident #1's erratic behavior and reported lack of SUD training |
| Staff D | Certified Nursing Assistant (CNA) | Worked overnight shift when Resident #1 returned from hospital; reported lack of SUD training |
| Staff E | Certified Nursing Assistant (CNA) | Observed Resident #1's erratic behavior and reported need for SUD training |
| Staff F | Minimum Data Set (MDS) Coordinator | Shared concerns about Resident #1's room placement and rumors of substance use |
| Nurse Consultant | Reported lack of orders for Resident #2's central line and questioned staff about Resident #1's substance use | |
| Regional Nurse Consultant | Informed about Resident #1's alleged drug possession and facility supervision practices |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Apr 28, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#127400-C, #127922-C, #128202-C) and a facility-reported incident (#128238-I) from April 28, 2025 to May 1, 2025.
Complaint Details
The visit was complaint-related involving Complaints #127400-C, #127922-C, #128202-C, and a facility-reported incident #128238-I. Complaints #127922-C and #128202-C resulted in deficiencies.
Findings
The facility was found deficient in quality of care related to failure to provide assessments, obtain orders, or follow up with a physician for a resident with a central line. Additionally, the facility failed to ensure an effective behavioral health program for a resident with substance use disorder, including lack of staff training and inadequate care plans.
Deficiencies (2)
Facility failed to provide assessments, obtain orders, or follow up with physician on a resident with an identified central line.
Facility failed to ensure the behavioral health program was effective for a resident with Substance Use Disorder, including lack of staff training and inadequate care plans.
Report Facts
Census: 65
BIMS score: 14
BIMS score: 15
Drug test count: 1
Date of Compliance: May 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Erin Martin | ARNP | Provided orders to remove Resident #2's central line prior to survey |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 3, 2025
Visit Reason
A revisit of the survey ending December 19, 2024, and investigation of Complaints #125824-C, #125825-C, and #126311-C was conducted from February 03, 2025 to February 06, 2025.
Complaint Details
Complaints #125824-C, #125825-C, and #126311-C were investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective January 23, 2025. Complaints #125824-C, #125825-C, and #126311-C were not substantiated.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 13
Date: Jan 23, 2025
Visit Reason
Annual Recertification Survey conducted from December 2, 2024 to December 19, 2024 to assess compliance with federal regulations for Pine Acres Rehabilitation and Care Center.
Findings
The survey identified multiple deficiencies including failure to complete background checks prior to rehire, incomplete comprehensive care plans addressing medications and smoking, inaccurate care plan timing and revisions, inconsistent code status documentation, failure to provide diabetic shoes, inadequate supervision and safety measures for smoking residents, incomplete dialysis assessments, insufficient nursing staff response to call lights, incomplete food temperature and sanitation logs, unsanitary food storage, improper catheter care leading to UTI risk, and incomplete immunization documentation for influenza, pneumococcal, and COVID-19 vaccines.
Deficiencies (13)
Failed to complete criminal record and abuse registry check prior to employee rehire date.
Care plans failed to address high risk medications such as insulin and antidepressants and failed to follow care plan regarding smoking materials.
Failed to fully review and revise comprehensive care plans when residents had changes in advance directives and smoking status.
Failed to provide physician orders related to code status and accurately document in clinical records for residents.
Failed to ensure resident received diabetic shoes as ordered, resulting in foot ulcer and amputation.
Failed to provide adequate supervision and safety devices for residents who smoke and failed to use foot pedals when transferring resident in wheelchair.
Failed to consistently perform required pre-dialysis and post-dialysis assessments for a resident receiving dialysis.
Failed to provide sufficient nursing staff to respond timely to resident call lights and needs.
Failed to ensure food prepared and maintained at appropriate temperature and dishes sanitized properly due to incomplete logs.
Failed to ensure food stored in sanitary manner to prevent contamination including debris in freezer, uncovered fryer oil, and unlabeled cereal containers.
Failed to implement infection control practices during catheter care to prevent urinary tract infection.
Failed to ensure residents were provided influenza and pneumococcal immunizations or documentation of refusal or contraindication.
Failed to ensure residents were provided COVID-19 immunizations or documentation of refusal or contraindication.
Report Facts
Census: 61
Meals with incomplete food temperature logs: 24
Meals with incomplete food temperature logs: 24
Meals with incomplete food temperature logs: 13
Dishmachine logs missing sanitizer verification: 8
Dishmachine logs missing sanitizer verification: 16
Residents reviewed for immunizations: 5
Residents reviewed for dialysis: 1
Residents reviewed for staffing: 1
Residents reviewed for smoking supervision: 3
Residents reviewed for catheter care: 1
Residents reviewed for diabetic foot care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse | Named in background check deficiency related to rehire date |
| Staff H | Social Worker | Named in care plan and code status deficiencies |
| Staff M | MDS Coordinator | Named in care plan and code status deficiencies |
| Staff G | Shoe Vendor Office Manager | Named in diabetic shoe deficiency |
| Staff F | Medical Doctor | Named in diabetic shoe deficiency |
| Staff D | Certified Nursing Assistant | Named in smoking supervision and call light response deficiencies |
| Staff C | Certified Nursing Assistant | Named in smoking supervision deficiency |
| Staff K | Certified Medication Aide | Named in smoking supervision deficiency |
| Staff B | Certified Nurse Aide | Named in catheter care deficiency |
| Staff A | Registered Nurse | Named in dialysis assessment deficiency |
| Staff I | Certified Medication Aide | Named in code status deficiency |
| Staff J | Licensed Practical Nurse | Named in code status deficiency |
| Staff L | Registered Nurse | Named in smoking supervision deficiency |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 12
Date: Dec 19, 2024
Visit Reason
The inspection was conducted as an annual survey of Pine Acres Rehabilitation and Care Center to assess compliance with regulatory requirements across multiple areas including care planning, abuse prevention, life safety, infection control, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to complete criminal background checks prior to employee rehire, incomplete and inaccurate care plans especially related to medication and smoking safety, inconsistent documentation and communication of residents' code status, failure to provide diabetic shoes leading to a resident's foot amputation, inadequate supervision and safety measures related to resident smoking, incomplete dialysis assessments, insufficient staffing response to call lights, incomplete food temperature and sanitation logs, improper food storage, failure to implement infection control practices for catheter care, and incomplete documentation of immunizations including COVID-19 and pneumococcal vaccines.
Deficiencies (12)
Failed to complete a criminal record check and dependent adult/child abuse registry check prior to an employee's rehire date.
Failed to develop and implement a complete care plan addressing high risk medications and smoking safety.
Failed to develop the complete care plan within 7 days of the comprehensive assessment and revise it when residents had changes in advance directives and smoking status.
Failed to provide physician orders related to code status and accurately document in clinical records for emergency actions.
Failed to provide diabetic shoes as ordered, resulting in a foot ulcer and subsequent amputation.
Failed to ensure wheelchair foot pedals were used, provide supervision and safety aprons during resident smoking, and retrieve smoking materials from residents.
Failed to consistently perform required pre-dialysis and post-dialysis assessments for a resident receiving dialysis.
Failed to provide enough nursing staff to meet resident needs and respond timely to call lights.
Failed to ensure food was prepared and maintained at appropriate temperatures and dishes sanitized properly due to incomplete logs.
Failed to store food in a sanitary manner to prevent contamination and foodborne illness.
Failed to implement infection control practices to prevent urinary tract infection related to improper catheter care.
Failed to ensure residents were provided up to date pneumococcal and COVID-19 vaccinations with proper documentation.
Report Facts
Residents affected: 61
Deficiencies cited: 12
Food temperature log missing entries: 61
Dishmachine chemical sanitizer log missing entries: 24
Resident #32 diabetic shoe order date: Jul 10, 2024
Resident #32 foot ulcer measurement: 15
Resident #35 dialysis chair time: 745
Resident #51 call light response delay: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Nurse | Named in deficiency for failure to complete background check prior to rehire |
| Staff H | Social Worker | Involved in updating care plans and code status documentation |
| Staff M | MDS Coordinator | Responsible for care plan updates and notifications |
| Staff I | Certified Medication Aide (CMA) | Referenced in code status identification |
| Staff J | Licensed Practical Nurse (LPN) | Referenced in code status identification |
| Staff G | Shoe Vendor Office Manager | Reported communication issues regarding diabetic shoe order |
| Staff F | Medical Doctor (MD) | Provided medical opinion on diabetic shoe importance |
| Staff C | Certified Nursing Assistant (CNA) | Observed in catheter care and smoking supervision deficiencies |
| Staff B | Certified Nurse Aide (CNA) | Observed in catheter care deficiency |
| Staff A | Registered Nurse (RN) | Stated dialysis assessments should be completed and documented |
| Staff K | Certified Medication Aide (CMA) | Observed supervising smokers and handling smoking materials |
| Staff L | Registered Nurse (RN) | Documented confiscation of cigarettes from resident |
| Staff D | Certified Nursing Assistant (CNA) | Observed supervising smokers and delayed response to call light |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding care plans, smoking policy, catheter care, dialysis, and staffing |
| Administrator | Facility Administrator | Provided interviews regarding smoking policy and diabetic shoe order communication |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
A revisit of the survey ending October 10, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 17, 2024.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 20, 2024
Visit Reason
A revisit of the survey ending October 10, 2024 and October 31, 2024 was conducted on November 20, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 17, 2024.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Oct 31, 2024
Visit Reason
Investigation of complaint #124347-C and facility reported incidents #124267-I and #124302-I conducted from October 23 to October 31, 2024, related to resident elopement and supervision concerns.
Complaint Details
Complaint #124347-C was substantiated. Facility reported incidents #124267-I and #124302-I were substantiated. Immediate Jeopardy (IJ) was identified starting 10/21/24 and removed on 10/29/24 after corrective actions.
Findings
The facility failed to provide adequate supervision to prevent a cognitively impaired resident at risk for elopement from leaving the facility unsupervised, resulting in a fall and serious injury. The facility implemented corrective actions including re-evaluation of residents at risk, education of staff, and door/alarm inspections. The resident was found approximately 0.2 miles away after eloping and suffered C1 and C2 fractures.
Deficiencies (1)
Facility failed to ensure residents were adequately supervised to prevent elopement, resulting in a resident leaving the facility unsupervised and sustaining injury.
Report Facts
Resident elopement distance: 0.2
Resident census: 68
Elopement risk assessment score: 20
Fall risk assessment score: 13
Date of incident: Oct 21, 2024
Date of survey completion: Oct 31, 2024
Date of plan of correction completion: Nov 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Completed Admission Assessment for Resident #1. |
| Staff B | Licensed Practical Nurse | Completed Elopement Risk Assessment and responded to elopement alarm. |
| Director of Nursing | Director of Nursing | Named in investigation and corrective actions related to elopement incident. |
| Staff C | Certified Nursing Assistant | Provided statement regarding resident supervision. |
| Staff D | Director of Recreation | Provided statement and checked wander guard functionality. |
| Staff J | Registered Nurse | Responded to EMS and elopement incident. |
| Staff K | Supervisor with Hospice | Reported hospice visits and notification of elopement. |
| Staff N | Described procedures for locating missing residents and alarm response. | |
| Staff O | Certified Nursing Assistant | Described missing resident protocol and alarm response. |
| Staff P | Certified Nursing Assistant | Described elopement drill and missing resident search procedures. |
| Staff Q | Licensed Practical Nurse | Described alarm response and missing resident protocol. |
| Staff R | Social Services | Described alarm response and communication procedures. |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Oct 21, 2024
Visit Reason
The inspection was conducted due to a complaint and investigation of an elopement incident where a severely cognitively impaired resident (Resident #1) left the facility unsupervised, resulting in a fall and injury.
Complaint Details
The complaint investigation was substantiated. Resident #1, who was at risk for elopement and wore a wander guard bracelet, left the facility unnoticed and suffered a fall resulting in serious injury. The facility was unaware of the resident's absence until EMS contacted them after finding the resident outside.
Findings
The facility failed to provide adequate supervision to prevent Resident #1 from exiting the facility unsupervised, despite the resident wearing a wander guard bracelet. The resident was found approximately 0.2 miles away after a fall, sustaining fractures to the C1 and C2 vertebrae. The facility implemented immediate corrective actions including re-evaluation of elopement risk, staff education, door and alarm inspections, and updated care plans.
Deficiencies (1)
Failed to ensure residents were adequately supervised to prevent elopement, resulting in immediate jeopardy to resident health or safety.
Report Facts
Census: 68
Elopement Risk Assessment Score: 13
Elopement Risk Assessment Score: 19
Elopement Risk Assessment Score: 20
Distance resident ambulated before fall (miles): 0.2
Date of survey completion: Oct 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Completed admission assessment for Resident #1 |
| Staff B | Licensed Practical Nurse (LPN) | Completed Elopement Risk Assessment on 1/28/24 and responded to front door alarm on 1/28/24 |
| Staff C | Certified Nursing Assistant (CNA) | Reported not seeing residents leave or hearing alarms on 10/21/24 |
| Staff D | Director of Recreation | Observed Resident #1 in dining room and checked wander guard functionality |
| Staff E | Cook | Reported no residents outside when leaving at 1:55 PM on 10/21/24 |
| Staff F | Housekeeping Aide | Was cleaning Resident #1's room at 1:45 PM on 10/21/24 and saw Resident #1 walking around |
| Staff G | Dietary Aide | Saw Resident #1 at lunch around 12:30 PM on 10/21/24 |
| Staff H | Food Service Supervisor | Saw Resident #1 at lunch around 12:30 PM on 10/21/24 |
| Staff I | Certified Nursing Assistant (CNA) | Did not hear alarm or see Resident #1 leave building on 10/21/24 |
| Staff J | Registered Nurse (RN) | Was at nurse's station and assisted visitor who found Resident #1 outside on 10/21/24 |
| Staff K | Supervisor with hospice | Reported hospice visits and notification of elopement on 10/21/24 |
| Staff L | Certified Nursing Assistant (CNA) with hospice | Provided routine hospice visit on 10/21/24 |
| Staff M | Licensed Massage Therapist (LMT) with hospice | Was in house on 10/21/24 and notified staff Resident #1 was not in room |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to prevent accidents, specifically related to Resident #2 who experienced multiple falls within a short period.
Complaint Details
The visit was complaint-related due to Resident #2's multiple falls within three days, including a fall causing a right hip fracture. The resident was non-compliant with safety interventions and self-transferred without assistance. The complaint was substantiated by clinical record review, staff interviews, and hospital documentation.
Findings
The facility failed to ensure Resident #2 was free from accidents, resulting in multiple falls over three days, including one that caused a right hip fracture. Despite interventions such as gripper socks and call light usage, the resident self-transferred without assistance and did not consistently use safety measures.
Deficiencies (1)
Failure to ensure Resident #2 was free from accidents, resulting in multiple falls and a right hip fracture.
Report Facts
Resident census: 68
Falls: 3
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided statements regarding Resident #2's condition and interventions |
| Administrator | Administrator | Provided statements regarding care plan interventions and fall documentation |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Date: Oct 10, 2024
Visit Reason
The inspection was conducted from October 8 to October 10, 2024, as a result of investigations into multiple complaints (#121793-C, #123482-C, #123607-C, #123870-C) and a facility reported incident (#121998-I). Complaints #123607-C and #123870-C and the facility incident #121998-I were substantiated.
Complaint Details
The investigation was triggered by complaints #121793-C, #123482-C, #123607-C, #123870-C and a facility reported incident #121998-I. Complaints #123607-C and #123870-C and the facility incident #121998-I were substantiated.
Findings
The facility failed to ensure that Resident #2 was free from accident hazards, resulting in multiple falls within three days, including a fall that caused a right hip fracture. Despite interventions such as gripper socks and call light modifications, the resident self-transferred without assistance and did not consistently use safety measures, leading to injury.
Deficiencies (1)
Failure to ensure Resident #2 was free from accident hazards, resulting in multiple falls and a right hip fracture.
Report Facts
Resident census: 68
Falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided statements regarding Resident #2's falls and interventions |
| Administrator | Administrator | Provided statements regarding care plan interventions after Resident #2's falls |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 19, 2024
Visit Reason
The document is a plan of correction submitted by the facility following a survey to address deficiencies and demonstrate compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification of compliance effective July 19, 2024.
Inspection Report
Routine
Census: 55
Deficiencies: 5
Date: Jun 19, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of care, including laboratory services, accident prevention, incontinence care, respiratory care, and transportation services for residents.
Findings
The facility failed to obtain labs per physician orders for multiple residents, failed to provide adequate supervision to prevent falls, failed to provide appropriate incontinence care, failed to provide oxygen according to physician orders, and failed to arrange transportation for physician appointments for some residents.
Deficiencies (5)
Failed to obtain labs per Physician orders for 2 of 3 residents reviewed (Residents #2, #3).
Failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #3) for falls.
Failed to provide appropriate incontinence care for 1 of 3 residents reviewed (Resident #4).
Failed to provide oxygen according to physician orders for 3 of 4 residents reviewed (Residents #2, #6, and #7).
Failed to arrange and/or provide transportation services to Physician appointments for 2 out of 3 residents reviewed (Residents #2, #3).
Report Facts
Residents Affected: 2
Residents Affected: 1
Residents Affected: 1
Residents Affected: 3
Residents Affected: 2
Census: 55
Fall Risk Assessment Score: 18
Medication Dosage: 2.5
Oxygen Flow Rate: 5
Oxygen Flow Rate: 3
Oxygen Flow Rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Reported on 12/4/23 Resident #2 was short of breath and portable oxygen tank was empty |
| Staff B | Licensed Practical Nurse | Verified portable oxygen tank was empty for Resident #6 on 6/18/24 |
| Staff C | MDS Coordinator | Changed out portable oxygen tank for Resident #6 on 6/18/24 |
| Staff D | Certified Nursing Assistant | Reported Resident #3 walks independently and assisted Resident #4 with incontinence care |
| Staff F | Certified Nursing Assistant | Observed providing inadequate incontinence care to Resident #4 |
| Staff G | Transportation Aide | Rescheduled Resident #3's appointment and transported him on 6/4/24 |
| Staff H | Licensed Practical Nurse | Reported Resident #3 walks with his walker by himself |
| Staff I | Certified Medication Aide | Reported Resident #3 was supposed to have assistance of one but walks independently |
| Staff J | Certified Nursing Assistant | Reported Resident #3 was independent with his walker |
| Staff E | Physical Therapy Assistant | Verified Resident #7's oxygen tank needed to be changed |
| DON | Director of Nursing | Verified missing labs, oxygen tank issues, and supervision concerns |
| Administrator | Reported Resident #2 used outside transportation service | |
| Senior Manager | Outside Transportation Company | Reported Resident #2 was not scheduled for transportation on missed appointment dates |
| Provisional Administrator | Reported unawareness of Resident #3's rescheduled appointment |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 5
Date: Jun 19, 2024
Visit Reason
The inspection was conducted as an investigation of Complaints #120257-C, #121407-C, and Facility Reported Incident #121444-I from June 11 to June 19, 2024. The complaints and incident were substantiated.
Complaint Details
The visit was triggered by substantiated complaints #120257-C and #121407-C, and a substantiated facility reported incident #121444-I.
Findings
The facility failed to provide care and services according to accepted professional standards for multiple residents, including failure to obtain labs per physician orders, inadequate nursing supervision to prevent falls, improper incontinence care, failure to provide oxygen therapy as ordered, and failure to arrange transportation for physician appointments.
Deficiencies (5)
Failed to provide care and services according to accepted standards for 2 of 3 residents by not obtaining labs per physician orders.
Failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents related to falls.
Failed to provide appropriate incontinence care for 1 of 3 residents reviewed.
Failed to provide oxygen according to physician orders for 3 of 4 residents reviewed.
Failed to arrange and/or provide transportation services to physician appointments for 2 of 3 residents reviewed.
Report Facts
Residents reviewed: 3
Residents reviewed: 4
Resident census: 55
Fall Risk Assessment score: 18
Oxygen liters ordered: 5
Oxygen liters observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | LPN | Reported Resident #2's portable oxygen tank was empty on 12/4/23 and switched to concentrator |
| Staff B | LPN | Reported unfamiliarity with Vikor urine specimen collection and verified empty oxygen tank for Resident #6 |
| Staff D | CNA | Observed providing incontinence care with deficiencies and reported assisting Resident #6 without checking oxygen tank |
| Staff F | CNA | Observed providing inadequate incontinence care with improper glove use and hand hygiene |
| Staff G | Transportation Aide | Rescheduled Resident #3's appointment and reported late notification of appointment |
| DON | Director of Nursing | Verified missing lab results, inadequate supervision, improper incontinence care, and oxygen therapy failures |
| Senior Manager | Transportation Company | Reported Resident #2 was not scheduled for transportation on missed appointment dates |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
The document serves as a Plan of Correction following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective April 22, 2024.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Apr 3, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to give medications as directed per physicians' orders and failure to provide two baths a week as required for several residents.
Complaint Details
The complaint investigation found substantiated failures in medication administration and bathing care. The Regional Director of Operations and Interim Administrator confirmed that physicians' orders were not followed and baths were not completed twice a week as expected.
Findings
The facility failed to administer medications as ordered for 2 residents and failed to provide two baths per week for 3 residents reviewed. The facility acknowledged these failures and confirmed staff are expected to follow physicians' orders and provide required care.
Deficiencies (2)
Failed to give medications as directed per physicians orders for 2 residents (Resident #1 and Resident #6).
Failed to provide two baths a week as directed for 3 residents (#1, #2, and #3).
Report Facts
Residents affected: 2
Residents affected: 3
Census: 56
Medication dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Administrator | Interviewed and confirmed expectations for staff to follow physicians orders and provide two baths a week | |
| Regional Director of Operations | Interviewed and confirmed physicians orders were not followed |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Mar 25, 2024
Visit Reason
The inspection was conducted as an investigation of multiple complaints (#119460-C, #119294-C, #119688-C, #119913-C) and a facility reported incident (#119484-I) from March 25, 2024 to April 3, 2024.
Complaint Details
Complaints #119294-C and #119688-C were substantiated.
Findings
The facility failed to meet professional standards in providing services, including failure to administer medications as ordered for residents and failure to provide adequate bathing care for dependent residents. The complaints #119294-C and #119688-C were substantiated.
Deficiencies (2)
Facility failed to give medications as directed per physician orders for 2 or 4 residents reviewed.
Facility failed to provide two baths a week as directed for 3 out of 4 residents reviewed.
Report Facts
Residents reviewed: 4
Residents affected: 2
Residents affected: 3
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Reviewed MAR & TAR, labs, and implemented corrective actions related to medication and bathing deficiencies |
| Interim Administrator | Stated expectation that staff follow physician orders and verified bathing schedules |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2024
Visit Reason
The state survey agency conducted an investigation into intake 112264-M, which ended on August 31, 2023.
Complaint Details
Investigation into intake 112264-M ended with no deficiencies identified.
Findings
The survey staff did not identify any deficiencies during the investigation.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
A revisit of the survey ending December 21, 2023 and investigation of multiple complaints and facility reported incidents was conducted from January 29, 2024 to February 1, 2024.
Complaint Details
The visit included investigation of Complaints #117895-C, #117898-C, #118139-C, #118296-C, #118427-C, #118524-C and Facility Reported Incidents #118326-I and 118465-I. All deficiencies were corrected.
Findings
All deficiencies identified in the prior survey and complaint investigations were corrected, and the facility was found to be in substantial compliance effective January 25, 2024.
Report Facts
Denial of Payment for Admissions (DPNA) duration: 110
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 7
Date: Dec 21, 2023
Visit Reason
A revisit of previous surveys and investigation of multiple complaints and facility reported incidents was conducted from December 11, 2023 to December 21, 2023. Several complaints and incidents were substantiated.
Complaint Details
The visit was triggered by multiple complaints (#116722-C, #116928-C, #117063-C, #117159-C, #117385-C) and facility reported incidents (#116474-I, #116931-I). Complaints #116722-C, #116928-C, #117063-C, #117159-C, and #117385-C were substantiated. Facility reported incident #116474-I was substantiated.
Findings
The facility was found deficient in multiple areas including failure to follow physician's orders for wound care and medication administration, failure to reorder medications timely, failure to provide adequate incontinence care, failure to ensure call lights were accessible to residents, failure to keep medication and treatment carts locked, and failure to maintain an effective infection prevention and control program. Repeated deficiencies were noted from prior surveys.
Deficiencies (7)
Failed to follow physician's orders for wound care including cleansing wound after soiled dressing removal, hand hygiene, and glove changes during treatment (Resident #11).
Failed to ensure timely reorder of Albuterol inhaler and follow physician's orders for daily weights and notification of significant weight gains (Resident #9).
Failed to provide appropriate incontinence care to prevent cross contamination and infection (Residents #11 and #12).
Failed to ensure call light within reach for residents (Residents #11 and #12).
Failed to ensure treatment and medication carts kept locked when unattended by staff.
Failed to have an effective quality assurance program to address repeated deficiencies and improve quality of care.
Failed to ensure infection prevention and control practices including hand hygiene, glove use, and proper wound care procedures. Failed to wear gloves during blood sugar check (Resident #7).
Report Facts
Resident census: 57
Weight gains: 14.7
Weight gains: 13.8
Medication reorder threshold: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in wound care deficiency and medication reorder issues |
| Staff B | Licensed Practical Nurse | Named in medication reorder and inhaler order issues |
| Staff C | Certified Nursing Assistant | Named in incontinence care deficiency |
| Staff F | Certified Nursing Assistant | Named in incontinence care deficiency |
| Staff I | Assistant Director of Nursing | Provided expectations on infection control and call light accessibility |
| Staff E | Registered Nurse | Provided information on medication cart locking issues |
| Corporate Nurse | Provided information on medication reorder and inhaler orders | |
| Infection Preventionist | Provided infection control expectations and observations |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 6
Date: Dec 20, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding wound care, medication administration, weight monitoring, incontinence care, call light accessibility, medication cart security, and infection control practices at Pine Acres Rehabilitation and Care Center.
Complaint Details
The visit was complaint-related, triggered by allegations of inadequate wound care, medication management, weight monitoring, incontinence care, call light accessibility, medication cart security, and infection control practices.
Findings
The facility failed to follow physician orders for wound care and hand hygiene, timely reorder medications including an Albuterol inhaler, properly monitor and notify weight changes for a resident with congestive heart failure, provide appropriate incontinence care to prevent infection, ensure call lights were within reach of residents, keep treatment and medication carts locked when unattended, and implement effective infection prevention and control practices including glove use and hand hygiene.
Deficiencies (6)
Failed to follow physician's orders for wound cleansing and hand hygiene during treatment and dressing changes for Resident #11.
Failed to timely reorder Albuterol inhaler and follow physician's orders for weight monitoring and notification for Resident #9 with congestive heart failure.
Failed to provide appropriate incontinence care to prevent cross contamination and infection for Residents #11 and #12.
Failed to ensure call lights were within reach for Residents #11 and #12.
Failed to keep treatment and medication carts locked when unattended for multiple halls.
Failed to implement effective infection prevention and control program including proper glove use, hand hygiene, wound care, incontinence care, and blood sugar testing procedures.
Report Facts
Resident census: 57
Weight gain: 14.7
Weight gain: 12
Medication doses left: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Named in wound care and medication administration deficiencies |
| Staff B | Licensed Practical Nurse | Named in medication reorder and inhaler delivery issues |
| Staff C | Certified Nursing Assistant | Named in wound care and incontinence care deficiencies |
| Staff I | Assistant Director of Nursing | Provided expectations on glove use, hand hygiene, and call light placement |
| Corporate Nurse | Reported on medication orders, inhaler delivery, and treatment cart issues | |
| Infection Preventionist | Provided infection control expectations and observations |
Inspection Report
Census: 73
Deficiencies: 9
Date: Oct 25, 2023
Visit Reason
The inspection was conducted to investigate multiple complaints and incidents related to resident care, abuse allegations, medication administration, wound care, falls, supervision, and staffing at Pine Acres Rehabilitation and Care Center.
Complaint Details
The complaint investigation included allegations of abuse by staff, failure to provide timely medical care and follow-up, inadequate supervision leading to resident elopement and injury, failure to provide scheduled personal care, and medication administration errors. The facility failed to timely report and investigate abuse allegations and failed to separate the alleged abuser from the victim.
Findings
The facility was found deficient in multiple areas including failure to treat a resident with dignity, failure to timely notify physicians of clinical issues, failure to report abuse allegations timely, failure to investigate abuse and separate alleged abusers, failure to provide appropriate supervision, failure to follow medication orders, failure to provide scheduled baths, failure to provide adequate wound care leading to amputation, failure to ensure medication cart security, and failure to complete annual staff performance evaluations.
Deficiencies (9)
Failed to treat a resident with respect and dignity, including rough handling during repositioning.
Failed to notify the facility physician timely of a urinary analysis that was not collected in a timely manner due to contamination.
Failed to timely report suspected abuse and failed to separate alleged abuser from victim.
Failed to respond appropriately to alleged violations, including failure to investigate a fall resulting in fracture and failure to identify use of gait belt.
Failed to provide care and services according to accepted standards, including failure to follow up on appointments, failure to administer medications as ordered, and failure to provide wound care leading to amputation.
Failed to provide two baths per week as directed for multiple residents.
Failed to ensure adequate supervision to prevent accidents, including failure to use gait belt during transfer resulting in fracture and failure to provide 1:1 supervision leading to resident elopement.
Failed to ensure medication cart was locked when unattended on multiple occasions.
Failed to complete annual performance evaluation for one employee.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 6
Residents affected: 73
Severity counts: 6
Severity counts: 2
Severity counts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Certified Nursing Assistant | Named in abuse allegation against Staff N |
| Staff N | Certified Nursing Assistant | Alleged abuser in abuse allegation and worked shifts after incident |
| Staff A | Certified Nursing Assistant | Involved in fall incident resulting in resident fracture |
| Staff B | Certified Nursing Assistant | Failed to provide 1:1 supervision leading to resident elopement |
| Staff C | Registered Nurse | Responded to fall incident and documented injury |
| Staff D | Licensed Practical Nurse | Assessed resident after fall incident |
| Staff E | Licensed Practical Nurse | Responded to resident elopement incident |
| Staff F | Licensed Practical Nurse | Observed inadequate supervision by Staff B |
| Staff G | Licensed Practical Nurse | Responsible for medication cart found unlocked |
| Staff J | Licensed Practical Nurse | Responsible for medication cart found unlocked and involved in abuse allegation reporting |
| Staff L | Licensed Practical Nurse | Confirmed abuse reporting and medication administration issues |
| Staff P | Certified Nursing Assistant/Certified Medication Aide | Confirmed baths/showers not completed as scheduled |
| Staff Q | Registered Nurse | Administered medication incorrectly |
| Staff K | Certified Medication Aide | Reported baths not being completed due to staffing |
| Staff H | Registered Nurse | Reviewed appointment scheduling and follow-up |
| Staff I | Licensed Practical Nurse (MDS Coordinator) | Confirmed lack of weekly skin assessments |
| Administrator | Facility Administrator | Confirmed failures in abuse reporting, skin assessments, and supervision |
| Interim Director of Nursing | Interim Director of Nursing | Confirmed failures in abuse reporting and supervision |
Inspection Report
Census: 73
Deficiencies: 11
Date: Oct 25, 2023
Visit Reason
The inspection was conducted based on complaint investigations and facility reported incidents related to resident rights, notification of changes, abuse allegations, and quality of care concerns.
Complaint Details
The visit was complaint-related, triggered by multiple substantiated complaints and facility reported incidents involving resident rights violations, abuse allegations, failure to notify changes, and quality of care concerns.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to notify physicians timely of changes in condition, failure to report and investigate abuse allegations promptly, failure to provide care according to professional standards including missed appointments and medication administration errors, failure to provide adequate bathing and personal care, failure to assess and manage wounds leading to severe complications, failure to provide adequate supervision to prevent accidents and elopement, insufficient nursing staff to meet resident needs, failure to complete annual nurse aide performance reviews, and failure to secure medication carts properly.
Deficiencies (11)
Failure to treat a resident with respect and dignity, including improper repositioning causing distress.
Failure to notify physician timely of urinary analysis results and changes in resident condition.
Failure to report alleged abuse immediately and to appropriate authorities within required timeframes.
Failure to thoroughly investigate abuse allegations and separate alleged abuser from victim.
Failure to provide care and services according to accepted professional standards including missed follow-up appointments and incorrect medication administration timing.
Failure to provide two baths per week as directed for dependent residents.
Failure to provide ongoing assessment and intervention for a resident with an unstageable wound leading to severe infection and amputation.
Failure to ensure resident environment is free of accident hazards and provide adequate supervision to prevent accidents and elopement.
Failure to provide sufficient nursing staff to meet resident care needs including bathing.
Failure to complete annual nurse aide performance evaluation.
Failure to ensure medication carts were locked and secured when unattended.
Report Facts
Deficiencies cited: 11
Resident census: 73
Staff N work shifts: 2
Baths missed: 9
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Certified Nursing Assistant | Named in abuse allegation and failure to follow proper repositioning and reporting procedures. |
| Staff M | Certified Nursing Assistant | Named as reporter of abuse allegation against Staff N. |
| Staff A | Certified Nursing Assistant | Named in fall incident resulting in resident injury due to failure to use gait belt. |
| Staff B | Certified Nursing Assistant | Named in failure to provide 1:1 supervision leading to resident elopement. |
| Staff G | Licensed Practical Nurse | Named in medication cart left unlocked. |
| Staff L | Licensed Practical Nurse | Named in medication cart left unlocked and medication administration errors. |
| Staff F | Licensed Practical Nurse | Named in medication cart left unlocked and failure to provide 1:1 supervision. |
| Staff H | Registered Nurse | Named in failure to assure follow-up appointments and medication administration. |
| Staff I | Licensed Practical Nurse | Named in failure to complete wound assessments. |
| Staff J | Assistant Director of Nursing | Named in abuse investigation and reporting. |
| Staff C | Registered Nurse | Named in fall incident investigation. |
| Staff E | Licensed Practical Nurse | Named in failure to provide 1:1 supervision. |
| Staff K | Certified Medication Aide | Named in failure to provide baths and medication administration. |
Inspection Report
Routine
Census: 79
Deficiencies: 26
Date: Aug 16, 2023
Visit Reason
The inspection was a routine survey of Pine Acres Rehabilitation and Care Center to assess compliance with healthcare regulations, including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, infection control, medication management, staffing, care planning, abuse prevention and investigation, pressure ulcer care, nutrition, respiratory care, and discharge planning. Several residents reported staff being rough during care, delays in call light response, and inadequate assistance with activities of daily living. The facility failed to ensure accurate assessments, timely interventions, and proper documentation in many cases.
Deficiencies (26)
Failed to treat residents with dignity and respect; staff spoke in a derogatory manner and did not follow care plans for toileting assistance for multiple residents.
Failed to document and act upon resident isolation status and infection control precautions for a resident with a history of resistant infections.
Failed to act on grievances voiced in Resident Council meetings and night shift resident meetings regarding staff attitude and responsiveness.
Failed to provide ready access to residents' personal funds managed by the facility, causing delays and resident frustration.
Failed to maintain accurate and timely accounting of resident personal funds deposits, resulting in delayed crediting and missed appointments.
Failed to accurately document advance directives; resident's code status was incorrectly entered in the electronic health record.
Failed to notify physician and family of a resident's change in condition, including skin breakdown and jerking movements, resulting in hospitalization.
Failed to ensure residents had a clean and homelike environment; observed stained carpeting and damaged floor tiles posing safety risks.
Failed to protect residents from abuse; multiple residents reported staff roughness during care, and the facility failed to thoroughly investigate and report allegations.
Failed to report suspected abuse allegations timely to the State Agency and thoroughly investigate all allegations.
Failed to thoroughly investigate all allegations of abuse and separate alleged abusers from residents, resulting in continued risk.
Failed to verify dependent adult abuse mandatory reporter training was current for staff and failed to perform criminal background and abuse registry checks prior to hire for a staff member.
Failed to ensure accurate Minimum Data Set (MDS) assessments reflective of residents' status, including diagnoses and medication use.
Failed to provide a bed hold and notify resident or family about bed hold policy when resident was transferred to hospital.
Failed to implement care plan interventions for dialysis assessments and failed to ensure transportation to dialysis for a resident.
Failed to implement care plan interventions for activities of daily living including bathing, positioning, oral care, incontinence care, and clean clothing for multiple residents.
Failed to provide adequate assessment and timely intervention for a resident with skin breakdown and change in condition, resulting in hospitalization and harm.
Failed to provide timely and adequate nutrition and hydration, including documentation of intake and weight monitoring for a resident at risk for altered nutritional status.
Failed to provide ongoing assessment and oversight of residents before and after dialysis treatments and failed to ensure transportation to dialysis for a resident.
Failed to provide safe and appropriate pain management for a resident, including inconsistent administration of pain medication and lack of timely response to pain complaints.
Failed to ensure availability of routine ordered medications and failed to establish a system for disposition and reconciliation of controlled drugs.
Failed to ensure timely call light response times for multiple residents, resulting in prolonged wait times and resident complaints.
Failed to ensure incontinence cares were provided in a timely manner, resulting in a resident sitting in a pool of urine.
Failed to ensure portable oxygen tanks were available for a resident requiring supplemental oxygen.
Failed to ensure glucometers were cleansed between uses and failed to follow infection control measures during medication administration.
Failed to employ a qualified Infection Preventionist for a period of 7 weeks.
Report Facts
Residents reviewed: 24
Residents reviewed: 12
Residents reviewed: 5
Residents reviewed: 18
Residents reviewed: 3
Residents reviewed: 4
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 21
Residents reviewed: 12
Residents reviewed: 4
Residents reviewed: 2
Residents reviewed: 2
Residents reviewed: 1
Residents reviewed: 2
Staff reviewed: 8
Staff reviewed: 6
Medication error rate: 10.71
Staff shifts worked: 21
Staff shifts worked: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Certified Nursing Assistant | Named in abuse allegation and investigation |
| Staff Q | Certified Nursing Assistant | Named in resident complaint of rough care |
| Staff FF | Certified Nursing Assistant | Named in resident complaint and disciplinary action |
| Staff HH | Certified Nursing Assistant | Named in resident complaint of rough care |
| Staff B | Licensed Practical Nurse | Named in notification of resident toe injury and licensure verification failure |
| Staff E | Licensed Practical Nurse | Named in resident toe injury and rough care complaint |
| Staff A | Certified Medication Aide | Named in medication error and portable oxygen tank inventory |
| Staff R | Certified Nurse Aide | Named in resident toe injury notification and incontinence care |
| Staff JJ | Registered Nurse | Named in abuse investigation and resident care observation |
| Staff L | Certified Nurse Aide | Named in resident rough care complaint and incontinence care |
| Staff M | Certified Nurse Aide | Named in resident rough care complaint and incontinence care |
| Staff MM | Certified Nurse Aide | Named in incontinence care observation |
| Staff NN | Speech Language Pathologist | Named in resident care observation |
| Staff W | Licensed Practical Nurse | Named in resident call light and toileting concern |
| Staff C | Licensed Practical Nurse | Named in resident complaint and staff statement |
| Staff GG | Certified Nurse Aide | Named in resident complaint and staff statement |
| Staff CC | Certified Nurse Aide | Named in resident complaint |
| Staff II | Social Services Assistant | Named in reporting resident care concerns |
| Staff U | Licensed Practical Nurse | Named in medication misappropriation investigation |
| Staff V | Certified Medication Aide | Named in medication misappropriation investigation |
| Staff H | Certified Medication Assistant | Named in medication availability |
| Staff K | Certified Medication Aide | Named in food temperature and call light response |
| Staff DD | Certified Nurse Aide | Named in resident condition observation |
| Staff EE | Certified Nurse Aide | Named in resident condition observation |
| Staff T | Licensed Practical Nurse | Named in MDS assessment and medication review |
| Staff X | Licensed Practical Nurse | Named in medication review |
| Staff S | Nurse Practitioner | Named in resident care and medication review |
| Staff F | Director of Rehabilitation | Named in resident care observation |
| Staff B | Licensed Practical Nurse | Named in resident care and medication error |
| Staff L | Certified Nurse Aide | Named in resident care and call light response |
Inspection Report
Routine
Census: 79
Deficiencies: 13
Date: Aug 16, 2023
Visit Reason
The inspection was a routine survey of Pine Acres Rehabilitation and Care Center to assess compliance with regulatory requirements including resident rights, infection control, care and services, environment, and medication management.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, failure to provide ready access to personal funds, failure to notify physician and family of change in condition, failure to maintain a clean and safe environment, failure to plan resident discharge properly, failure to provide adequate assistance with activities of daily living, failure to provide timely assessment and intervention for changes in condition, failure to prevent avoidable pressure ulcers, failure to analyze falls and implement interventions, failure to provide adequate nutrition and hydration, failure to provide necessary respiratory care, failure to ensure adequate staffing for timely call light response, failure to provide pharmaceutical services including medication availability and accountability, and failure to maintain medication error rates below 5 percent.
Deficiencies (13)
Failure to treat residents with dignity and respect including derogatory staff behavior and confinement without clinical indication.
Failure to provide ready access to resident's personal funds managed by the facility causing delays and frustration.
Failure to notify physician and family of resident's change in condition resulting in delayed treatment and hospitalization.
Failure to maintain a clean and homelike environment including stained carpets, dislodged carpet tile strips, and warped floor tiles.
Failure to plan resident discharge to meet goals and needs including failure to notify contact person when resident left against medical advice and lack of discharge planning.
Failure to provide adequate assistance with activities of daily living including bathing, positioning, oral care, incontinence care, and clean clothing.
Failure to provide adequate assessment and timely intervention for changes in condition including untreated skin breakdown and delayed hospital transfer.
Failure to implement and carry out interventions to prevent avoidable pressure ulcers resulting in harm.
Failure to analyze cause of falls and provide interventions to prevent further falls.
Failure to assure adequate nutrition and hydration including lack of documentation of intake and weight monitoring.
Failure to provide necessary respiratory care by failing to provide portable oxygen tanks.
Failure to ensure enough nursing staff to meet resident needs and timely call light response.
Failure to provide pharmaceutical services including medication availability, accountability, and preventing medication errors.
Report Facts
Census: 79
Medication error rate: 10.71
Number of falls: 25
Number of residents reviewed for ADL assistance: 12
Number of residents reviewed for pressure ulcers: 3
Number of residents reviewed for respiratory care: 1
Number of residents reviewed for medication availability: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Z | Certified Nurse Aide | Named in medication error finding and disrespectful behavior toward Resident #37 |
| Staff Y | Certified Nurse Aide | Named in disrespectful behavior toward Resident #37 |
| Staff R | Certified Nurse Aide | Notified nurse about Resident #56's injured toenail |
| Staff B | Licensed Practical Nurse | Involved in Resident #56's toenail injury and medication availability |
| Staff E | Licensed Practical Nurse | Measured and treated Resident #26's heel pressure ulcers |
| Staff A | Certified Medication Aide | Involved in medication error with Resident #274 |
| Staff H | Certified Medication Assistant | Noted medication unavailability for Resident #177 |
| Staff U | Licensed Practical Nurse | Involved in medication misappropriation investigation for Resident #60 |
| Staff V | Certified Medication Aide/Scheduler | Involved in medication misappropriation investigation for Resident #60 |
| Staff CC | Certified Nurse Aide | Recalled Resident #77 scratching and having areas on her arms |
| Staff DD | Certified Nurse Aide | Reported not receiving shift report for Resident #77 |
| Staff EE | Certified Nurse Aide | Reported not receiving shift report for Resident #77 |
| Staff JJ | Registered Nurse | Observed incontinence care for Resident #46 |
| Staff LL | Certified Nurse Aide | Involved in toileting and care of Resident #46 |
| Staff MM | Certified Nurse Aide | Involved in toileting and care of Resident #46 |
| Staff O | Certified Nurse Aide | Reported difficulty answering call lights timely |
| Staff J | Licensed Practical Nurse | Reported call light response delays on second shift |
| Staff K | Certified Medication Aide | Observed ignoring call light |
| Staff AA | Certified Nurse Aide | Observed ignoring call light |
| Staff BB | Licensed Practical Nurse | Observed ignoring call light |
| Staff S | Advanced Registered Nurse Practitioner | Commented on Resident #77's condition and care |
| Staff F | Director of Rehabilitation | Involved in Resident #53's care and environmental observations |
| Staff G | Certified Medication Aide | Attempted to move lift over carpet tile transition strip |
| Staff B | Licensed Practical Nurse | Completed admission assessment for Resident #230 |
| Staff C | Licensed Practical Nurse | Reported transferring Resident #77 to hospital |
Inspection Report
Routine
Census: 79
Deficiencies: 43
Date: Aug 16, 2023
Visit Reason
Routine annual recertification and complaint investigation survey conducted to assess compliance with resident rights, care, safety, and regulatory requirements.
Complaint Details
Multiple residents reported staff being rough during cares and disrespectful behavior by staff. Several staff members were suspended and terminated following investigations. The facility failed to report and investigate all allegations of abuse timely and thoroughly. Resident #276 reported a staff member slapped her on the back and was rough. Resident #32 reported staff were rude and condescending. Resident #7 reported night staff were rude and rough. Resident #65 reported staff were rough when changing him. Resident #24 reported staff were rough and hurt her. The facility conducted interviews with residents and family members and provided education to staff on abuse prevention and reporting.
Findings
The facility was found deficient in multiple areas including resident rights violations, failure to address resident grievances, mismanagement of personal funds, inaccurate advance directive documentation, failure to notify family and physician of changes, unsafe environment, abuse and neglect issues, medication errors, infection control lapses, and inadequate staffing.
Deficiencies (43)
Failure to treat residents with respect and dignity; staff spoke in derogatory manner and confined residents without clinical indication.
Failure to act on grievances voiced in Resident Council meetings for multiple months.
Failure to provide ready access to residents' personal funds managed by the facility.
Failure to maintain accurate accounting records for residents' personal funds.
Failure to accurately document advance directives for a resident.
Failure to notify physician and family of resident's change in condition.
Failure to maintain a safe, clean, comfortable, and homelike environment; stained carpets and damaged flooring.
Failure to provide an environment free from physical abuse; multiple residents reported staff roughness and disrespect.
Failure to develop and implement written policies ensuring dependent adult abuse training and background checks for staff.
Failure to report all allegations of abuse to the State Agency within required timeframes.
Failure to thoroughly investigate all allegations of abuse and separate alleged perpetrators from residents.
Failure to provide bed hold notice to resident or representative upon transfer to hospital.
Failure to ensure accuracy of Minimum Data Set assessments reflecting resident status and diagnoses.
Failure to coordinate PASARR evaluations timely and accurately.
Failure to develop and implement comprehensive care plans reflecting resident needs including hospice, communication, and fall prevention.
Failure to provide services consistent with professional standards including following physician orders and ensuring dialysis care.
Failure to provide sufficient nursing staff to ensure timely call light response and resident assistance.
Failure to provide necessary Activities of Daily Living assistance including bathing, positioning, oral care, and incontinence care.
Failure to maintain food temperatures and serve palatable meals at appropriate temperatures.
Failure to ensure food safety by serving expired food and failing to label and date opened food items.
Failure to verify staff licensure prior to hire.
Failure to follow infection control practices including disinfecting glucometers and safe medication administration.
Failure to maintain a qualified infection preventionist with current certification.
Failure to ensure tuberculosis testing for newly hired staff prior to employment.
Failure to provide adequate nutrition and hydration; failure to document supplement intake and weights.
Failure to provide respiratory care including availability of portable oxygen tanks.
Failure to provide adequate pain management including timely medication administration and reassessment.
Failure to ensure dialysis care including pre and post assessments and transportation.
Failure to update and revise care plans timely to reflect resident needs including hospice, communication, and fall prevention.
Failure to follow physician orders including medication administration and lab monitoring.
Failure to implement timely discharge planning and notify family of resident decisions.
Failure to provide adequate Activities of Daily Living assistance including bathing, toileting, and incontinence care.
Failure to provide quality care including timely assessment and intervention for change in condition and pressure ulcer prevention and treatment.
Failure to analyze falls and implement interventions to prevent further falls.
Failure to provide bowel and bladder incontinence care in a timely manner.
Failure to ensure medication availability and accurate controlled substance reconciliation.
Failure to ensure psychotropic medications are administered only for diagnosed conditions and PRN orders have appropriate rationale and duration.
Failure to maintain food palatability and temperature during meal service.
Failure to ensure food safety by discarding expired food and labeling opened food items.
Failure to verify staff licensure prior to hire.
Failure to follow infection control practices including disinfecting glucometers and safe medication administration.
Failure to maintain a qualified infection preventionist with current certification.
Failure to ensure tuberculosis testing for newly hired staff prior to employment.
Report Facts
Medication error rate: 10.71
Residents interviewed for abuse: 10
Residents interviewed for abuse: 10
Expired food items found: 38
Call light response time: 15
Falls in 3 months: 25
Medication administration errors: 11
Missed dialysis treatments: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Certified Nursing Assistant | Named in abuse and roughness allegations, suspended and terminated |
| Staff Q | Certified Nursing Assistant | Named in abuse and roughness allegations, suspended and terminated |
| Staff FF | Certified Nursing Assistant | Named in abuse and roughness allegations, suspended and terminated |
| Staff HH | Nurse | Named in abuse allegations, terminated |
| Staff Z | Certified Nursing Assistant | Named in disrespectful behavior to resident, suspended and terminated |
| Staff B | Licensed Practical Nurse | Named in medication administration and licensure verification issues |
| Staff JJ | Registered Nurse | Named in TB testing deficiency and abuse investigation |
| Staff A | Certified Medication Aide | Named in medication administration error and infection control lapses |
| Staff I | Licensed Practical Nurse | Named in infection control lapses |
| Staff E | Licensed Practical Nurse | Named in wound care and abuse investigation |
| Staff R | Certified Nurse Aide | Named in incontinence care and abuse investigation |
| Staff LL | Certified Nurse Aide | Named in incontinence care lapses |
| Staff M | Certified Nurse Aide | Named in incontinence care lapses |
| Staff MM | Certified Nurse Aide | Named in incontinence care lapses |
| Staff S | Nurse Practitioner | Named in psychotropic medication management and wound care |
| Staff W | Licensed Practical Nurse | Named in abuse investigation and notification lapses |
Inspection Report
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The inspection was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The nursing home was found to be in compliance with the applicable federal requirements as of the inspection date.
Inspection Report
Routine
Census: 83
Deficiencies: 8
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, safety, discharge procedures, care provision, pressure ulcer prevention, medication administration, staffing, and other aspects of nursing home care.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to maintain a safe and clean environment, inadequate discharge documentation and procedures, failure to provide scheduled showers, medication administration errors, inadequate pressure ulcer care, and delayed response to call lights.
Deficiencies (8)
Failure to treat residents with dignity, including pulling a resident backwards in a wheelchair and calling residents by names of endearment without care plan preferences.
Failure to keep a resident's room sanitary and orderly, with clutter covering more than half the room and impeding care.
Failure to provide adequate discharge documentation and planning for a resident discharged from the facility.
Failure to permit a resident to return to the nursing home after hospitalization due to lack of documentation and inability to meet resident's needs.
Failure to provide twice weekly showers to a resident requiring extensive assistance.
Failure to apply prescribed treatment cream per doctor's orders and medication administration error involving eye drops given to both eyes instead of one.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including delayed assessment and treatment of wounds.
Failure to answer call lights in a timely manner, with an observation of a call light left unanswered for over 50 minutes.
Report Facts
Residents affected: 83
Shower frequency: 1
Pressure ulcer size: 5.5
Hematoma size: 2.3
Call light wait time: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Observed pulling Resident #19 backwards in wheelchair and calling residents by names of endearment |
| Staff H | Registered Nurse (RN) | Provided treatment to Resident #20's foot wounds and discussed wound care for Resident #17 |
| Staff A | Licensed Practical Nurse (LPN) | Signed off on applying treatment cream to Resident #11 but did not apply it |
| Staff F | Nurse Supervisor, Licensed Practical Nurse (LPN) | Reviewed Resident #7's progress notes and discussed AMA paperwork and resident behavior |
| Staff G | Nursing Supervisor | Discussed Resident #7's behavior and AMA paperwork |
| Staff I | Licensed Practical Nurse (LPN) | Administered eye drops to Resident #21 incorrectly |
| Staff J | Licensed Practical Nurse (LPN) | Assessed wounds on Resident #17 and discussed wound care |
| Staff K | Occupational Therapist (OT) | Notified nursing of skin integrity concerns for Resident #17 |
| Staff D | Certified Nurse Aide (CNA) | Assisted Resident #11 after long wait for call light response |
| Administrator | Acknowledged call light response issues and discussed Resident #7's discharge and readmission issues | |
| Director of Nursing (DON) | Acknowledged call light response issues and discussed wound care and other deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Pine Acres Rehabilitation and Care Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 7
Date: Apr 4, 2023
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and to investigate multiple complaints and facility-reported incidents from February 14, 2023 to April 4, 2023.
Complaint Details
The visit was complaint-related involving multiple substantiated complaints and facility-reported incidents including issues with resident dignity, discharge procedures, and care quality.
Findings
The facility was found in compliance with COVID-19 practices but had multiple deficiencies including failure to treat residents with dignity, failure to maintain a safe and clean environment, failure to properly document and manage resident transfers and discharges, failure to provide adequate ADL care including showers, failure to follow professional standards for medication administration, and failure to prevent and treat pressure ulcers.
Deficiencies (7)
Facility failed to treat residents with dignity, including pulling a resident backwards in a wheelchair and calling residents by names of endearment without care plan direction.
Facility failed to keep a resident's room sanitary and orderly, with clutter covering most surfaces and floor space.
Facility failed to provide proper documentation and follow discharge regulations for a resident who left against medical advice and was not permitted to return.
Facility failed to provide twice weekly showers to a resident requiring extensive assistance.
Facility failed to follow professional standards of practice for medication administration, including leaving treatment cream on bedside table and administering eye drops to both eyes instead of one.
Facility failed to provide assessment and intervention to prevent pressure ulcer development, resulting in a Stage 3 pressure ulcer and hematoma not assessed or treated timely.
Facility failed to answer call lights in a timely manner, with a call light observed on for over 50 minutes without response.
Report Facts
Total Residents: 83
Deficiencies cited: 7
Resident #17 showers: 1
Pressure ulcer size: 5.5
Pressure ulcer size: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Observed pulling resident backwards in wheelchair and calling residents by names of endearment |
| Staff H | Registered Nurse (RN) | Administered treatment and called resident by inappropriate name |
| Staff F | Nurse Supervisor, Licensed Practical Nurse (LPN) | Reviewed wound care and described resident agitation and AMA process |
| Staff J | Licensed Practical Nurse (LPN) | Reviewed wound areas and medication administration |
| Staff I | Licensed Practical Nurse (LPN) | Administered eye drops to wrong eye and reported error |
| Staff G | Nursing Supervisor, Licensed Practical Nurse (LPN) | Discussed resident wanting to leave and AMA process |
| Staff E | Certified Nurse Aide (CNA) | Responded to call light after long delay |
| Staff D | Certified Nurse Aide (CNA) | Assisted resident after call light delay |
| Staff K | Occupational Therapist (OT) | Notified nursing of skin integrity concerns |
| Administrator | Acknowledged issues with resident dignity, discharge, and call light response | |
| Director of Nursing (DON) | Acknowledged call light response issues and reviewed wound care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
A complaint investigation was conducted for complaints #104862-C, #107051-C, #107225-C, and #107472-C, as well as facility reported incidents #107216-I and #10748-I from September 13, 2022 to September 23, 2022.
Complaint Details
Investigation involved multiple complaints and facility reported incidents; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 5, 2022
Visit Reason
The document is a plan of correction accepted following a survey and investigation ending May 31, 2022, to certify the facility in compliance effective August 5, 2022.
Findings
The facility submitted a credible allegation of compliance and plan of correction after the survey and investigation, resulting in certification of compliance effective August 5, 2022.
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 12
Date: May 31, 2022
Visit Reason
The inspection was conducted as the facility's annual recertification survey and investigation of multiple complaints and a facility-reported incident.
Complaint Details
Complaints #97182-C and #98375-C were substantiated. Complaint #102364-C was substantiated without deficiency. Complaints #98822-C, #100258-C, and #101472-C were unsubstantiated. Facility-reported incident #102590-I was substantiated.
Findings
The facility was found deficient in multiple areas including failure to ensure a homelike environment with clean bed linens, inadequate investigation of abuse allegations, failure to notify the Long Term Care Ombudsman of resident transfers, incomplete bed hold notices, inaccurate assessments, incomplete care plans, failure to provide restorative activities, insufficient nursing staff to provide timely assistance, unsanitary kitchen conditions, and failure to administer influenza vaccine to a resident.
Deficiencies (12)
Failure to ensure a homelike environment by not providing clean bed linens and consistently making the bed for a resident with incontinence.
Failure to conduct a thorough investigation following a family concern related to medication administration for a resident.
Failure to notify the Long Term Care Ombudsman of resident transfers to hospital for three residents.
Failure to provide resident or representative notice of bed hold policy at time of hospital transfer for two residents.
Failure to submit a PASRR for a resident with newly diagnosed mental disorder.
Failure to develop and implement a baseline care plan within 48 hours of admission for a resident.
Failure to develop comprehensive care plans addressing psychotropic and pain medications for multiple residents.
Failure to ensure medication administration by licensed staff only, proper documentation, and proper disposal of refused medications for a resident.
Failure to provide restorative activities to maintain functional range of motion and prevent decline in activities of daily living for a resident.
Failure to ensure sufficient nursing staff to provide timely assistance to a resident requiring two-person assist.
Failure to maintain clean and sanitary kitchen conditions including sticky floors, carbon buildup on stove, and dirty microwave and steam table.
Failure to administer influenza vaccine to a resident who consented and lacked documentation of education or communication regarding vaccine administration.
Report Facts
Complaints investigated: 6
Facility-reported incidents investigated: 1
Residents present: 69
Residents reviewed: 24
Residents reviewed for immunizations: 5
Residents reviewed for medication administration: 6
Residents reviewed for restorative activities: 6
Residents reviewed for care plans: 19
Residents reviewed for nursing staff assistance: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nurse Aide | Named in medication administration finding related to Resident #67 |
| Staff I | Registered Nurse | Named in medication administration finding related to Resident #67 |
| Staff H | Registered Nurse | Named in medication administration finding related to Resident #67 |
| Staff G | Licensed Practical Nurse | Named in medication administration finding related to Resident #67 |
| Staff E | Interim Director of Nursing | Named in medication administration finding related to Resident #67 |
| Staff D | Assistant Director of Nursing | Named in immunization and psychotropic medication monitoring findings |
| Staff J | Physical Therapist | Named in restorative activities finding related to Resident #10 |
| Staff B | Certified Medication Aide | Named in restorative activities finding |
Inspection Report
Renewal
Census: 52
Deficiencies: 3
Date: Mar 16, 2021
Visit Reason
The inspection was a recertification survey conducted from 03/10/2021 to 03/16/2021 to assess compliance with federal regulations for Pine Acres Rehabilitation and Care Center LLC.
Findings
The facility was found deficient in documenting residents' wishes regarding resuscitation and advance directives for three of five residents reviewed, and failed to resubmit a Preadmission Screening and Resident Review (PASARR) after a change in diagnosis and medication for one resident. Additionally, the facility failed to submit timely veteran admissions information for two residents.
Deficiencies (3)
Failure to ensure adequate documentation of resident wishes for resuscitation and advance directives for three residents.
Failure to resubmit a Preadmission Screening and Resident Review (PASARR) after a change in diagnosis and medication for one resident.
Failure to submit veteran admissions information to the Iowa Department of Veteran Affairs within 30 days for two residents.
Report Facts
Residents present: 52
Residents reviewed for advance directives: 5
Resident admissions reviewed for veteran status submission: 32
Residents with late veteran status submission: 2
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Feb 2, 2021
Visit Reason
The inspection was conducted due to investigation of Incident #95225-I and Complaint #93980-C between 1/25/21 and 2/2/21.
Complaint Details
Incident #95225-I was substantiated. Complaint #93980-C was not substantiated.
Findings
The facility failed to ensure adequate supervision to prevent elopement for one of three residents reviewed, resulting in Resident #1 being found outside the building without staff awareness. The facility's investigation confirmed the incident and identified deficiencies in supervision and alarm response.
Deficiencies (1)
Facility failed to ensure each resident received adequate supervision to prevent elopement for 1 of 3 residents reviewed.
Report Facts
Resident census: 56
Residents reviewed: 3
Resident MDS assessment date: Nov 30, 2020
Wandering Assessment date: Oct 19, 2020
Elopement Incident Report date: Jan 21, 2021
Weekly Test of Door Alarm Systems date: Jan 14, 2021
Date of compliance: Feb 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Prepared Elopement Incident Report and documented nursing progress note |
| Staff B | Certified Nurse Aide (CNA) | Interviewed regarding resident supervision and elopement incident |
| Staff C | Certified Nurse Aide (CNA) | Interviewed regarding resident supervision and elopement incident |
| Staff D | Certified Nurse Aide (CNA) | Interviewed regarding resident supervision and elopement incident |
| Staff E | Screener | Interviewed regarding resident supervision and elopement incident |
| Staff F | Dietary Aide | Interviewed regarding resident supervision and elopement incident |
| Administrator | Interviewed and confirmed staff training and facility investigation findings | |
| Director of Nursing | Director of Nursing (DON) | Interviewed and confirmed staff training and facility investigation findings |
| Social Worker | Interviewed regarding resident elopement and wandering behavior |
Inspection Report
Routine
Census: 55
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/28/2020 through 12/29/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control during the survey conducted December 7-9, 2020.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Sep 17, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted in conjunction with investigation of complaint #93053-C and #92899-C on 9-16-20 thru 9-17-20.
Complaint Details
Complaints #93053 and #92889 were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Complaints #93053 and #92889 were not substantiated.
Report Facts
Total residents: 65
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigation of complaint #89178-C and facility reported incidents #92265-I and #92768-I on August 17-20, 2020.
Complaint Details
Investigation of complaint #89178-C and facility-reported incidents #92265-I and #92768-I were not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Investigation of complaint #89178-C and facility-reported incidents #92265-I and #92768-I were not substantiated.
Report Facts
Complaint number: 89178
Facility reported incident numbers: 92265
Facility reported incident numbers: 92768
Inspection Report
Routine
Census: 65
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 7/14/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Date: Jun 18, 2020
Visit Reason
A focused COVID-19 infection survey was conducted in conjunction with investigation of complaints #89217-C and #90365-C from June 11-18, 2020. The investigation of complaint #89217-C resulted in deficiencies, while complaint #90365-C did not.
Complaint Details
Investigation of complaint #89217-C resulted in deficiencies; investigation of complaint #90365-C did not result in deficiencies.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19. However, a deficiency was cited for failure to include the resident or resident representative in the initial care plan process and failure to create an initial comprehensive care plan for 1 of 4 residents reviewed (Resident #4).
Deficiencies (1)
Failure to include the resident or resident representative in the initial care plan process and failure to create an initial comprehensive care plan for Resident #4.
Report Facts
Total residents: 67
BIMS score: 14
Dates of care plan updates: Multiple dates from 1/20/20 to 5/5/20 noted for care plan updates for Resident #4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Responded regarding lack of initial comprehensive care plan for Resident #4 and described care plan update process |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 3
Date: Jan 30, 2020
Visit Reason
Investigation of the facility's self-reported incidents and complaints related to abuse, neglect, and misappropriation of resident property.
Complaint Details
The investigation was triggered by complaints #88785-C and #87244-C, and self-reported incidents #88116-M and #88810-1. Complaint #87799-C was not substantiated.
Findings
The facility failed to investigate injuries of unknown origin including bruises and skin tears on residents, and failed to investigate an allegation of missing resident property. Additionally, the facility failed to report reasonable suspicion of a crime related to a missing resident's wedding ring and failed to follow care plan interventions for a resident with fragile skin.
Deficiencies (3)
Failed to investigate injuries of unknown origin including bruises on 2 residents and skin tears on 1 resident, and failed to investigate an allegation of missing resident property for 1 resident.
Failed to report reasonable suspicion of a crime when a resident's wedding ring was reported missing.
Failed to follow care plan interventions to maintain the highest physical, mental and psychosocial well-being for a resident with fragile skin.
Report Facts
Census: 74
Skin tear measurement: 8
Skin tear measurement: 1
Bruise measurement: 4
Bruise measurement: 5
BIMS score: 7
Date of survey: Jan 30, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse (RN) | Nurse on duty who assessed bruises and was involved in incident reporting |
| Staff D | Certified Nursing Assistant (CNA) | Reported resident was agitated and combative, assisted with transfers |
| Staff E | Certified Nursing Assistant (CNA) | Involved in resident transfers and alleged to have slapped resident's leg |
| Director of Nursing (DON) | Director of Nursing | Responsible for staff education and investigation oversight |
| Staff C | Social Worker | Involved in searching for missing resident property and communicating with responsible party |
| Staff F | Certified Medication Aide (CMA) | Reported skin tears and bruises on resident to nurse |
Report
Jan 8, 2026
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