CMS Inspection Results for PINES REHAB & HEALTH CTR

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 12/10/2008 Fire Safety Survey for PINES REHAB & HEALTH CTR

Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm

 

• 12/04/2008 Health Survey for PINES REHAB & HEALTH CTR

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Widespread	Minimal harm or potential for actual harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
Give professional services that meet a professional standard of quality.	Isolated	Actual harm
Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm

 

• 10/31/2007 Health Survey for PINES REHAB & HEALTH CTR

Environmental
Deficiency	Scope	Level of Harm
Make sure that staff members wash their hands when needed.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm

 

• 10/29/2007 Fire Safety Survey for PINES REHAB & HEALTH CTR

Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm

 

• 11/01/2006 Health Survey for PINES REHAB & HEALTH CTR

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Potential for minimal harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm

 

• 10/30/2006 Fire Safety Survey for PINES REHAB & HEALTH CTR

Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
properly located and lighted Exit signs.	Pattern	Minimal harm or potential for actual harm