Pine Acres Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF600Aug 16, 2023

  Based on observation, clinical record review, policy review, staff interview, and resident interview, the facility failed to provide an environment free from physical abuse for 7 residents who reported staff were rough with them during cares (Residents #7, #10, #24, #26, #32, #65, and #276) and failed to treat a resident with respect for 1 of 1 residents observed during a general observation (Resident #37). A serious adverse outcome was likely to occur as the facility additionally failed to report and thoroughly investigate all allegations of abuse. One identified staff member whom residents reported an issue with remained actively working with access to all residents. Additionally, without the thorough investigation, it was unknown if other staff members could be identified. […]

• Immediate jeopardy, widespreadF609Aug 16, 2023

  Based on clinical record review, policy review, staff interview, and resident interview, the facility staff failed to ensure 5 allegations were reported to the Administrator and the State Agency (SA). Five residents reported allegations of staff being rough with cares (Residents #7, #10, #32, #65, and #276). Staff interviews confirmed that staff were aware of residents verbalizing allegations of roughness during cares with no evidence the allegations were reported to the SA. A serious adverse outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. One identified staff member whom residents reported an issue with remained actively working with access to all residents. […]

• Immediate jeopardy, widespreadF610Aug 16, 2023

  Based on clinical record review, policy review, staff interview, and resident interview, the facility staff failed to thoroughly investigate all allegations of abuse, and separate an possible abuser from residents. Five residents reported staff were rough during cares(Residents #7, #10, #32, #65, and #276). The facility lacked documentation of thorough investigations. The facility failed to conduct resident and staff interviews to determine the extent of the allegations, if other residents and/or staff involved. A serious adverse outcome was likely to occur as the facility failed to report and thoroughly investigate all allegations of abuse. One identified staff member whom residents reported an issue with remained actively working with access to all residents. […]

• Immediate jeopardy, patternF684Jun 3, 2026

  Based on clinical record review, staff interview, observation, and facility policy review, the facility failed to conduct comprehensive, ongoing nursing assessment and interventions for 7 of 7 residents reviewed for significant changes of condition (Resident #2, #7, #93, #71, #41, #83, #94). Resident #2 fell out of bed on [DATE] striking his face on the floor sustaining injury. The resident was sent to the emergency room (ER) where a nose fracture was ruled out and he returned to the facility. The morning of [DATE] the resident complained of pain and transferred back to the ER returning with orders for 5 days of antibiotic medication to treat a diagnosed UTI (Urinary Tract Infection) with hematuria (blood in urine). […]

• Immediate jeopardy, patternF686Jun 3, 2026

  Based on clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to implement preventive measures for a resident at risk of developing pressure sores for 4 of 4 residents reviewed for pressure sore prevention and interventions (Resident #73, #83, #85, #94). The facility failed to utilize a pressure reducing wheelchair cushion until after Resident #73 developed an avoidable facility-acquired Stage 4 (full-thickness skin damage) pressure sore to the lower right posterior thigh (which presented with eschar [dead tissue] and treated with antibiotic), failed to maintain pressure relief to the area once developed, and failed to provide major reposition changes and incontinence care over a 7.5 hour period based on a continuous… […]