College Pines Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Mar 6, 2024

  Based on record review and Medical Doctor (MD) and staff interviews, the facility failed to notify the MD or on-call provider when Resident #1, who was on anticoagulant medication and had a history of brain bleeds, had an unwitnessed fall with obvious head injury for 1 of 3 residents reviewed for accidents and notification. On 02/13/24 at approximately 1:30 AM Resident #1 was found lying on the floor of her room in between the bed and wall with her head next to the nightstand. Upon assessment by Nurse #1, Resident #1 had a laceration to the right eyebrow area, a quarter-sized hematoma to the right forehead, and bruising to the right hand. Resident #1 exhibited no signs of respiratory distress. […]

• Immediate jeopardy, isolatedF684Mar 6, 2024

  Based on record review and Medical Doctor (MD) and staff interviews, the facility failed to recognize the seriousness of a head injury following a fall and seek medical treatment for a resident on Eliquis (anticoagulant medication) with a history of brain bleeds for 1 of 3 residents reviewed for accidents (Resident #1). On 02/13/24 at approximately 1:30 AM Resident #1 was found lying on the floor of her room in between the bed and wall with her head next to the nightstand. Upon assessment by Nurse #1, Resident #1 had a laceration to the right eyebrow area, a quarter-sized hematoma to the right forehead, and bruising to the right hand. Resident #1 exhibited no signs of respiratory distress. […]

• Actual harm, isolatedF690Mar 24, 2021

  Based on record review, observations, resident and staff interviews, the facility failed to prevent a latex urinary catheter from being inserted into a resident using latex gloves with a latex allergy and failed to assess the situation for 1 of 3 residents (Resident #76) reviewed for urinary catheters. Resident #76 told a total of 4 staff members before her catheter was changed that she was experiencing symptoms of an allergic reaction. As a result, Resident #76 experienced burning, itching, pain and swelling for a 28-hour period. The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #76's face sheet revealed her allergies listed were latex and tape. […]

• No harm, potential for more than minimal, isolatedF641Apr 29, 2026

  Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications for 1 of 5 sampled residents (Resident #6). The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia (high blood sugar).A review of Resident #6's physician admission orders dated 02/16/26 revealed an order for Lantus Solostar U-100 insulin (long-acting insulin and hypoglycemic medication used to manage blood glucose levels) 100 units per milliliter. […]

• No harm, potential for more than minimal, isolatedF867Mar 6, 2024

  Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 03/26/21. This was for two repeat deficiencies in the areas of quality of care and notification that were originally cited during the recertification and complaint investigation survey completed on 03/26/21 and subsequently recited during the complaint investigation completed on 03/06/24. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. […]