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Deficiency Records for Pine Creek Rehabilitation and Nursing
A list of the most recent deficiencies for Pine Creek Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pine Creek Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-27 | 2023-04-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-27 | 2023-04-28 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-27 | 2023-04-20 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-27 | 2023-04-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-03-02 | 2023-04-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-03-02 | 2023-04-06 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-03-02 | 2023-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-02 | 2023-04-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-02 | 2023-04-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-02 | 2023-04-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-03-02 | 2023-04-06 | N |
| Meet other general requirements. | Fire Safety | 2023-02-27 | 2023-03-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-27 | 2023-03-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-27 | 2023-03-02 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-08-18 | 2021-10-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-18 | 2021-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-18 | 2021-10-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-18 | 2021-10-06 | N |
| Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. | Health | 2021-08-18 | 2021-10-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-24 | 2021-09-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-24 | 2021-09-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-24 | 2021-08-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-07-02 | 2019-08-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-07-02 | 2019-08-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-07-02 | 2019-08-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-07-02 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-02 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-02 | 2019-08-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-07-02 | 2019-08-16 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2019-07-02 | 2019-08-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-02 | 2019-08-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-07-02 | 2019-08-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-02 | 2019-08-16 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-07-02 | 2019-08-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-02 | 2019-08-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-02 | 2019-08-16 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2019-07-02 | 2019-08-16 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2019-07-02 | 2019-08-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-02 | 2019-08-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-07-09 | 2019-07-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-09 | 2019-07-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-07-09 | 2019-07-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-07-09 | 2019-07-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-09 | 2019-07-22 | N |
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