Alcoa Pines Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Alcoa Pines Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 27, 2023

  Based on record review and interview, the facility failed to ensure two staff members were present when transferring a resident who required two-person assistance to prevent accident and injury for 1 (Resident #1) of 4 sampled residents. This failed practice resulted in findings of Past non-compliance. The findings are: 1. Resident #1 was admitted on [DATE]. The Admission/ Medicare 5-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2023 documented the resident is total dependence of two+ persons for transfer. a. The closet care plan with an admitted [DATE] noted Resident #1 had total dependence on staff with two+ persons physical assist with transfers. b. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2024

  Surveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and that the refrigerator temperature was maintained at 41 degrees Fahrenheit or below to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who received meals from the kitchen. The findings are: 1. On 03/17/2024 at 10:33 AM, the following observations were made in the kitchen: a. A step on trash can was leaning against the grill and against the hand washing sink. b. […]

• No harm, potential for more than minimal, widespreadF812Sep 17, 2021

  Based on observation and interview, the facility failed to ensure dietary staff completely covered their hair while assisting with lunch and supper meal preparations; expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen; food items stored in the storage area were sealed to maintain freshness and prevent potential cross contamination and dietary staff washed their hands between dirty and clean tasks and before handling clean dishes or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. […]

• No harm, potential for more than minimal, patternF602Aug 28, 2026

  Number of residents sampled: Number of residents cited: Based on record review, interview, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident's property. Specifically, medications were signed out of the Narcotic Book and not given to 12 (Residents #53, #65, #81, #91, #94, #95, #96, #98, #100, #112, #114, and #115) of 23 residents reviewed for misappropriation of property. The findings include: Resident #53 Review of an admission Record revealed the facility admitted Resident #53 on 04/10/2024. The resident had a medical history that included diagnoses of heart failure, polyarthritis (5 or more joints are inflamed and painful) and gastrostomy status (feeding tube). […]

• No harm, potential for more than minimal, patternF759Aug 28, 2026

  Based on record review, observation, and interview the facility failed to ensure the medication error rate was not greater than 5% during the medication pass of two (Resident #6, Resident #20) of five resident reviewed. This surveyor observed 27 opportunities for medication administration and two of the 27 medications were not administered in accordance with the Physician's Orders, and administration guidelines resulting in a medication error rate of 7.41%. The findings include: Resident #20Review of an admission Record revealed the facility admitted Resident #20 on 01/05/2024. […]