Pine Acres Center for Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pine Acres Center for Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 28, 2024

  Based on record review, staff, resident, Emergency Service Services (EMS) Personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner, Medical Director, family, and Physician Assistant interviews the facility neglected to provide intravenous (IV) antibiotic medication as ordered for 14 days to a resident when his IV access became dislodged and neglected to direct him to a higher level of care, to replace the IV access line for 1 of 3 residents reviewed (Resident #244) for abuse/neglect. There was the the high likelihood of physical harm by not administering the IV antibiotic as ordered by the infectious disease clinic. The untreated bacterial infection had the high likelihood of causing loss of function to his extremities or possible amputation of his extremities. […]

• Immediate jeopardy, patternF684Mar 28, 2024

  Based on record review, staff, family, Emergency Medical Services (EMS) personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to send Resident #244 to the emergency room (ER) as directed by the Infectious Disease office on 07/14/23 to have his intravenous (IV) access restored and to resume his previously prescribed IV antibiotics. Resident #244's peripherally inserted central catheter (PICC) line became dislodged on 07/11/23 and on 07/14/23 Nurse #10 was notified by the Infectious Disease office to send Resident #244 to the ER to have his PICC line reinserted so that he could resume his antibiotics as ordered and Nurse #10 failed to send him to the ER. […]

• Immediate jeopardy, patternF760Mar 28, 2024

  Based on record review, staff, family, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to prevent a significant medication error when staff failed to administer 14 ordered doses of intravenous (IV) antibiotic from 07/11/23 to 07/24/23 after the residents peripherally inserted central catheter (PICC line) was dislodged for 1 of 2 residents reviewed for significant medication error (Resident #244). Resident #244's infection if left untreated could lead to loss of limb function. Immediate jeopardy began on 07/14/23 when Resident #244's PICC line become dislodged, and the facility failed to direct him to higher level of care to ensure he received the IV antibiotic he required. […]

• Immediate jeopardy, isolatedF607Mar 28, 2024

  Based on record review, staff, resident, and Physician's Assistant interviews the facility failed to immediately report an allegation of sexual abuse to the administrator for 1 of 3 residents reviewed for sexual abuse (Resident #38). A severely cognitively impaired female resident (Resident #38) was taken by a resident (Resident #241), a cognitively intact male resident, into the bathroom in his room. Resident #241's roommate, a cognitively intact male resident (Resident #47), used his call light to alert Nurse Aide (NA) #1 about Resident #241 and Resident #38. NA #1 did not report the allegation about Resident #241 and Resident #38 to a nurse. During this time when NA #1 did not report the allegation to a nurse, Resident #241 was in the bathroom with Resident #38. […]

• Immediate jeopardy, isolatedF660Mar 28, 2024

  Based on record review, resident, facility staff, and shelter staff interview the facility failed to develop and implement an effective discharge planning process to ensure discharge needs and goals were identified with the resident and the interdisciplinary team (IDT) as active participants in the discharge plan in order to prepare the resident for an effective transition to post-discharge care for a resident who was a planned discharge. On 2/14/24 Resident #241 was discharged without the facility verifying his discharge location and if his care needs were able to be met. In addition, the resident was discharged without adaptive equipment required for ambulation (rolling walker). […]