Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villa At Pine Place during CMS and state inspections, most recent first.
A resident with multiple comorbidities and total dependence on staff developed a sacral/coccyx wound that was inaccurately assessed and not properly managed. The wound was mischaracterized, not identified in routine assessments, and lacked appropriate interventions in the care plan. The facility failed to recognize the wound's decline or notify the physician, resulting in the resident's hospitalization for a Stage 4 pressure ulcer and sepsis.
The facility failed to maintain sanitary conditions in the kitchen and storage areas, affecting food safety. Raw ground beef was improperly thawed under warm running water, and undated containers of chicken tenders and sliced peaches were found in coolers. Additionally, debris was observed in the dry storage room, and the ice machine area had stagnant water and mold-like substances.
A resident and the Resident Council reported a lack of meaningful activities due to staffing shortages after a management change. The facility had only one activities director, leading to limited programs and no weekend activities. The Director of Activities and Administrator acknowledged the issue, with plans to increase staffing.
A resident with dysphagia and Parkinson's disease was observed coughing while consuming thin liquids, despite a physician's order for nectar thick liquids. The facility failed to provide the prescribed diet texture, leading to a deficiency in nutritional care.
A resident with severe cognitive impairment and a recent hospital readmission was not provided with the physician-ordered enteral feeding, and the facility failed to document the feeding accurately or notify the physician of refusals. The resident's legal representative was also not informed of the refusals, despite visiting daily. The facility's policy on feeding tubes was not followed, leading to a deficiency in care.
A resident with end-stage renal failure did not receive consistent post-dialysis assessments, and there was a lack of communication between the dialysis center and the facility. Nursing progress notes lacked documentation of dialysis port site assessments, and recent dialysis communication forms were missing from the resident's records. Interviews revealed confusion among staff about the process for handling dialysis communication forms, contributing to the deficiency.
The facility experienced insufficient staffing on weekends, resulting in extended call light response times and resident dissatisfaction. Three residents reported longer wait times for assistance, particularly during afternoon and midnight shifts. One resident faced difficulties with toileting due to a broken toilet and lack of staff. The facility's staffing report confirmed low weekend staffing, and interviews with staff indicated challenges due to call-offs. The Administrator and DON acknowledged the issues and were working to address them.
The facility failed to implement non-pharmacological interventions and gradual dose reductions (GDR) for residents on psychotropic medications. One resident with Alzheimer's and other disorders was on a regimen of Ativan, Benadryl, and Haldol gel without documented GDR attempts. Another resident with schizoaffective disorder received diazepam without prior non-pharmacological interventions. A third resident with major depressive disorder was given PRN lorazepam frequently without an end date or evidence of target behaviors. The DON acknowledged these concerns.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with pressure ulcers. The resident had multiple open wounds, but there was no signage indicating the need for EBP. A nurse provided wound care without wearing a gown, only using gloves. The resident's medical record showed a Stage 3 pressure injury, but no physician orders for EBP. The infection control nurse and DON confirmed that EBP should have been used, and acknowledged the lack of signage and PPE in the resident's room.
The facility did not effectively implement an antibiotic stewardship program, leading to inappropriate antibiotic use for three residents. The Unit Manager explained the process of ensuring infections meet McGeer's criteria before prescribing antibiotics. However, three residents were on antibiotics without meeting these criteria, and there was no physician documentation justifying the continued use. The Unit Manager could not provide supporting documentation for these cases.
A resident receiving hospice care with a documented high pain level did not receive prescribed pain medication due to a lapse in administration and documentation. The facility's DON confirmed the absence of pain relief on the day of hospice transfer, as the ordered Morphine was unavailable and the previous Norco prescription was discontinued.
A resident with severe cognitive impairment and multiple comorbidities was readmitted to a facility but did not receive critical medications for four days due to a failure in transcribing and following up on admission orders. The facility's process for verifying medication orders was not followed, leading to the oversight.
The facility failed to investigate a resident-to-resident sexual abuse allegation thoroughly. A cognitively intact resident reported inappropriate touching by another resident, but the facility did not interview the victim or obtain hallway footage. The Administrator dismissed the need for a formal interview, relying on conflicting staff reports.
The facility failed to update the care plan for a resident with a history of drug use after an overdose incident. The resident, who was cognitively intact, overdosed on drugs within the facility and was transferred to the hospital, where a urine drug screen confirmed cocaine use. Despite this, the care plan was not updated to include measures to monitor for signs of drug use or to more closely monitor visitors.
A resident with dementia and a history of traumatic brain injury eloped from the facility and was missing for four and a half hours. The facility failed to identify the resident as an elopement risk, did not have staff stationed at the front desk, and lacked clear procedures for responding to door alarms. Staff inconsistencies and inadequate policies contributed to the incident.
A resident with dementia and a history of traumatic brain injury exited the facility without staff knowledge and was missing for four and a half hours. The facility failed to ensure medically-related social services and follow-up, including guardianship and care planning reviews, due to the absence of a full-time social services staff and lack of documentation.
A resident with multiple diagnoses experienced significant weight loss and a decline in health due to the facility's failure to monitor their nutritional needs and weight. Despite being identified as malnourished, the resident did not receive the recommended nutritional supplement, and their weight was not monitored as required. Interviews with staff revealed inconsistencies in the weight monitoring process and lack of follow-up on the resident's nutritional status.
The facility failed to ensure a comprehensive infection control program, resulting in a resident developing a urinary tract infection and being hospitalized. The DON overseeing the program had not completed the necessary training, and the facility's infection control documents lacked essential elements such as calculated infection rates and environmental rounding.
A resident with multiple diagnoses waited nearly three hours for a brief change after activating their call light. Despite the issue being reported to the administration, no timely follow-up was conducted, and the grievance form was only initiated 14 days later. Staff education did not specifically address the incident.
Failure to Accurately Assess and Manage Pressure Ulcer Leading to Hospitalization
Penalty
Summary
The facility failed to accurately assess and manage a sacral/coccyx wound for a resident with dementia, gastrostomy, dysphagia, and total dependence on staff for activities of daily living. The initial wound assessment documented a new open area on the coccyx, but the wound was incorrectly described as moisture-associated skin damage (MASD) rather than a pressure injury, despite clinical findings consistent with a Stage 3 pressure wound. There was no documentation of the facility identifying the wound in weekly skin assessments, nor were adequate and appropriate interventions implemented in the care plan to prevent wound development. Over the following days, the facility did not identify the worsening of the wound or notify the physician of the resident's declining condition. The resident developed abnormal vital signs, altered mental status, and was eventually transferred to the hospital, where the wound was debrided and identified as a Stage 4 pressure ulcer with associated sepsis. The facility's records did not show timely recognition of the wound's deterioration or appropriate communication with the physician prior to the resident's hospitalization.
Sanitation Deficiencies in Kitchen and Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all residents consuming food from the kitchen. During an observation, two 10-pound packages of raw ground beef were found thawing under running water in a two-compartment sink. The ground beef was partially submerged in water, with the temperature of the running water measured at 92 degrees Fahrenheit, contrary to the FDA Food Code requirement of 70 degrees Fahrenheit or below. The Dietary Manager confirmed that the water should have been cold. Additionally, undated containers of chicken tenders and sliced peaches were found in the walk-in and reach-in coolers, respectively, violating the FDA Food Code requirement for date marking ready-to-eat, potentially hazardous food. Further observations revealed unsanitary conditions in the dry storage room and the nourishment room. The flooring underneath the racks in the dry storage room had a buildup of debris, including flour, chocolate chips, cups, and snack packages. In the nourishment room, the ice machine's drainage bin contained stagnant, standing water, and the flooring underneath was wet with a black mold-like substance. There was also an accumulation of trash on the floor underneath the ice machine, violating the FDA Food Code requirement for cleaning physical facilities as often as necessary to keep them clean.
Inadequate Activity Programming Due to Staffing Shortages
Penalty
Summary
The facility failed to provide consistent, meaningful, and person-centered activities for residents, as evidenced by the experiences of one resident and feedback from the Resident Council. One resident, who had intact cognition and a history of anxiety disorder, bipolar disorder, and depression, reported a lack of engaging activities since a change in management led to a reduction in activity staff. The resident expressed dissatisfaction with the limited activities available, such as bingo, and noted the absence of one-on-one activity visits from staff. The Resident Council, consisting of seven residents, corroborated these concerns, with five residents reporting a significant reduction in activities and staff following management changes. They noted that the facility currently had only one activities director, who struggled to manage the program alone. The residents highlighted the lack of activities on weekends and the reliance on volunteers and nursing staff to assist with activities, which was insufficient to meet their needs. Interviews with the Director of Activities and the Administrator confirmed the staffing challenges and the limited scope of the activities program. The Director of Activities acknowledged being the sole staff member since April 2024 and described efforts to manage group activities and one-on-one visits with limited resources. The Administrator recognized the issue and mentioned recent approval for a part-time staff member, with plans to increase staffing further. The facility's policy emphasized the importance of providing activities that support residents' physical, mental, and psychosocial well-being, which was not being adequately met.
Failure to Provide Prescribed Thickened Liquids
Penalty
Summary
The facility failed to provide liquids according to the prescribed therapeutic diet texture for a resident, leading to a deficiency in nutritional care. On the morning of September 9, 2024, a resident was observed in their room attempting to eat breakfast while seated in a wheelchair. During this time, the resident was seen coughing while consuming cereal and drinking juice, both of which appeared to be thin liquids. A review of the resident's meal ticket indicated that they were supposed to receive nectar thick liquids, but this was not provided. Nurse C was informed of the situation and upon assessment, confirmed that the liquids were not thickened as required. Nurse C then added thickener to the liquids. The resident's medical record revealed a history of dysphagia, mild-protein-calorie malnutrition, and Parkinson's disease, with a physician's order specifying a diet of soft and bite-sized texture with mildly thick/nectar consistency liquids. The care plan also highlighted the resident's potential for nutritional and hydration problems due to their medical history and mechanically altered diet. Despite these documented needs, the facility did not adhere to the prescribed dietary requirements, resulting in the resident receiving inappropriate liquid consistency during their meal.
Failure to Administer and Document Enteral Feeding
Penalty
Summary
The facility failed to provide the total amount of physician-ordered enteral feeding to a resident, document the feeding accurately, and ensure timely follow-up with the physician. The resident, who had severe cognitive impairment and was represented by a legal guardian, was observed with an unopened bottle of enteral feeding dated three days prior. The charge nurse reported that the resident had been refusing tube feeding for several days, despite needing it to meet nutritional needs due to inadequate food intake. The resident had recently returned from the hospital with a new diagnosis of a pelvic mass and was experiencing abdominal discomfort. The resident's electronic medical record showed an order for enteral feeding once a day, but there was no documentation of the resident receiving the feeding on multiple days. Additionally, there was no evidence that the medical provider was notified of the resident's refusals or an episode of vomiting. The legal representative was also not informed of the refusals, despite visiting the facility daily. The unit manager acknowledged that the staff should have notified the physician and dietitian and that the legal representative should have been informed. Interviews with the registered dietitian and the director of nursing revealed that the facility's process for handling feeding refusals was not followed. The dietitian was only notified after the issue was brought to the facility's attention, and the director of nursing confirmed that the situation should not have occurred. The facility's policy on feeding tubes emphasized the importance of following physician orders and notifying the physician of any complications, which was not adhered to in this case.
Failure to Ensure Consistent Dialysis Care and Communication
Penalty
Summary
The facility failed to consistently assess a resident after dialysis and maintain accessible communication and collaboration between the dialysis center and the facility. The resident, who had end-stage renal failure and severe cognitive impairment, was receiving dialysis four times a week. However, the nursing progress notes from August to September did not consistently document the assessment and monitoring of the dialysis port site or post-dialysis nursing assessments. Additionally, there was a lack of recent dialysis communication forms in the resident's clinical record, indicating a breakdown in communication between the facility and the dialysis center. Interviews with facility staff revealed confusion and lack of awareness regarding the process for handling dialysis communication forms. The Unit Manager admitted to being new to the facility and unaware of the proper procedure, while the Dialysis Manager explained that forms were supposed to be reviewed and followed up by facility staff. The Director of Nursing confirmed that the forms were not uploaded to the resident's electronic medical record as expected. The facility's policy required comprehensive care plans and coordination between the facility and the dialysis provider, but these were not effectively implemented, leading to the deficiency.
Insufficient Weekend Staffing Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to provide sufficient staffing on weekends, leading to inadequate care and services for residents. During a confidential Resident Council interview, three residents reported extended wait times for assistance after activating their call lights, particularly during afternoon and midnight shifts on weekends. One resident experienced a broken toilet over a weekend and struggled to receive help with toileting due to insufficient staff. Additionally, two residents noted that staff were often required to perform multiple roles, further exacerbating the issue. The facility's staffing report from April to June 2024 confirmed low weekend staffing levels. Interviews with the Unit Manager and a CNA revealed that staffing challenges were primarily due to staff call-offs, particularly on afternoon and midnight shifts. The facility Administrator acknowledged the staffing issues and attributed them to call-ins, while the Director of Nursing noted that staffing was improving but still faced challenges due to attendance issues. Both the Administrator and DON were aware of the concerns raised by residents and were working on addressing the staffing problems.
Failure to Implement GDR and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to implement non-pharmacological interventions and gradual dose reductions (GDR) for residents receiving psychotropic medications, as observed in three cases. One resident, diagnosed with Alzheimer's disease, major depressive disorder, anxiety disorder, and psychotic disorder with delusions, was on a regimen of Ativan, Benadryl, and Haldol gel for agitation, anxiety, and psychosis. Despite a behavioral consultant's note indicating no recent behavioral changes and a contraindication for GDR, there was no documentation of previous GDR attempts or other medication options since 2016. The facility's social worker confirmed the absence of documented GDR attempts and was unable to provide further explanation or documentation. Another resident with schizoaffective disorder, bipolar disorder, and anxiety disorder was prescribed diazepam as needed (PRN) for anxiety. The electronic medication administration record (EMAR) showed multiple administrations of diazepam without documented non-pharmacological interventions prior to its use. The Director of Nursing (DON) acknowledged that nursing staff should document attempted interventions in the progress notes before administering the medication. A third resident, with major depressive disorder and anxiety disorder, was receiving PRN lorazepam for agitation/anxiety without an end date on the order. The resident's medication administration record (MAR) indicated frequent administration of lorazepam without evidence of target behaviors or non-pharmacological interventions. The social worker confirmed the lack of documentation for target behavior monitoring and non-pharmacological interventions, and the DON acknowledged the concern regarding the absence of an end date and monitoring by floor staff.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were applied for a resident with pressure ulcers. On a specific date, a concern was submitted to the State Agency indicating that facility staff were not following infection control procedures. During an observation, a resident was found in their room without any signage indicating the need for EBP, despite having multiple open wounds on their heel and leg. A nurse was observed providing wound treatment to the resident without wearing a gown, only using gloves. The nurse confirmed that they did not use a gown and stated there was no indication on the resident's door that EBP was required. The resident's medical record revealed they had been admitted with diagnoses including Bipolar and Schizoaffective disorder, and had a BIMS score indicating moderately impaired cognition. A wound evaluation showed a Stage 3 pressure injury that was not healed. There were no physician orders for EBP in the medical record. During an interview, the infection control nurse and the Director of Nursing confirmed that staff should have been using EBP, including gowns, when providing direct care to the resident. They acknowledged the absence of signage and a PPE bin in the resident's room, which should have been present to inform staff of the necessary precautions.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to effectively implement an antibiotic stewardship program, resulting in the inappropriate use of antibiotics for three residents. During an interview, the Unit Manager (UM) explained the process of ensuring infections meet McGeer's criteria before antibiotics are prescribed. If criteria are not met, the provider is contacted to discontinue the medication, and a progress note should be written to justify continued use. However, a review revealed that three residents were on antibiotics without meeting McGeer's criteria, and there was no documentation from physicians justifying the continued use of these medications. The UM was unable to provide supporting documentation, such as physician notes, labs, or symptoms, for the continued antibiotic use in these cases.
Failure to Administer Pain Medication to Hospice Resident
Penalty
Summary
The facility failed to administer pain medication to a resident who required such services, as identified during a survey. The resident, who was receiving hospice care and had a terminal illness, was documented to have a pain level of seven out of ten. Despite having physician orders for pain management, including Norco and Morphine, the resident did not receive any pain medication on the day in question. The Norco prescription had been discontinued, and the Morphine ordered by hospice was not yet available, leaving the resident without pain relief. The Director of Nursing (DON) confirmed that there was no documentation of pain medication administration on the day the resident transferred to hospice care. Although two Norco pills were removed from the container, there was no record of them being given to the resident. The DON acknowledged that the nurse should have contacted the physician for an alternative pain relief order while waiting for the Morphine delivery. The lack of documentation and failure to administer pain medication as ordered resulted in the deficiency noted in the survey.
Failure to Transcribe and Administer Admission Medications
Penalty
Summary
The facility failed to accurately transcribe and follow up on admission orders for a resident, resulting in the resident missing four days of critical medications. The resident, who had severe cognitive impairment and multiple comorbidities, was readmitted to the facility after a hospital stay. Upon readmission, the facility did not order the medications listed in the hospital discharge summary, which included blood thinners, diabetic medications, blood pressure medications, and others. The resident's electronic medical record and medication administration record did not reflect the necessary medications, and the resident did not receive these medications until four days after readmission. Additionally, the facility staff failed to check the resident's blood sugar levels until several days after readmission, resulting in a high blood sugar level that was not addressed in a timely manner. The facility's process for verifying and reconciling medication orders was not followed, leading to the oversight. Interviews with facility staff, including the MDS Nurse and the Director of Nursing, revealed that the medication error was identified after the fact, and there was a lack of clarity on how the error occurred. The facility's process was supposed to involve verification of orders by the admitting nurse, unit managers, pharmacy, and attending physician, but this process was not effectively implemented in this case.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to complete a full investigation following an allegation of resident-to-resident sexual abuse involving two residents. Resident R701 reported that Resident R706 entered their room on two occasions, with the second incident involving inappropriate sexual touching. Despite R701's report, the facility did not conduct a thorough investigation, including failing to interview R701 about the incident. The facility's Administrator and Director of Nursing (DON) relied solely on staff reports that contradicted R701's account, without obtaining any hallway camera footage or conducting a comprehensive review of the incident. R701, who is cognitively intact with a BIMS score of 15/15, reported feeling unsafe and having issues with other residents and staff. The resident's clinical record did not contain any notes or follow-up regarding the alleged incident. R706, who is severely cognitively impaired and primarily speaks Spanish, was not appropriately interviewed due to language barriers. The facility's documentation included only brief and conflicting staff statements, with no formal interviews conducted with R701. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and interviews with all involved persons, including the alleged victim. However, the Administrator dismissed the need for an official interview with R701, citing the resident's history of making up stories and dissatisfaction with the living situation. This failure to adhere to the facility's policy and conduct a thorough investigation led to the deficiency cited in the report.
Failure to Update Care Plan for Resident with History of Drug Use
Penalty
Summary
The facility failed to develop a comprehensive care plan to address a resident's history of drug use. The resident, who had a history of drug use, was observed to have overdosed on drugs within the facility. On the day of the incident, the resident had left the facility on a leave of absence and returned later in the day. A few hours after returning, the resident became unresponsive, prompting the Director of Nursing (DON) to administer Narcan, suspecting an overdose. The resident was then transferred to the hospital, where a urine drug screen confirmed the presence of cocaine. Despite this incident, the resident's care plan was not updated to include measures to monitor for signs of drug use or to more closely monitor visitors, which the DON acknowledged should have been done to ensure the resident's safety. The resident's clinical records indicated that he was cognitively intact and had a history of drug use. The DON confirmed that the care plan had not been updated following the overdose incident, and there was no documentation of any measures taken to prevent future occurrences. The failure to update the care plan and implement appropriate monitoring measures constituted a deficiency in the facility's care planning process, as it did not adequately address the resident's needs and potential risks associated with his history of drug use.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent the elopement of a resident, identified as R704, who exited the facility without staff knowledge and was missing for four and a half hours. The resident, who had a history of dementia with behavioral disturbances and a traumatic brain injury, was not identified as an elopement risk prior to the incident. On the day of the incident, R704 was observed on video surveillance exiting the facility through the front door and was later found approximately 0.5 miles away by facility staff. The resident was wearing a wanderguard bracelet, which was applied after the elopement incident. The facility's response to the elopement was inadequate. Staff did not notice R704's absence until several hours later, and there was no immediate response to the door alarm that was triggered when the resident exited. The facility had no staff stationed at the front desk on the day of the incident, and the door alarm system was managed by the nursing station, which failed to follow through with a visual check of the area outside the door. Interviews with staff revealed inconsistencies in their accounts of the events and a lack of clear procedures for responding to door alarms. The facility's policies and procedures for handling elopements and door alarms were found to be insufficient. The maintenance director confirmed that there was no documentation available for when the alarm was silenced, and the facility's elopement policy did not provide specific guidelines for staff response to door alarms. The administrator admitted that staff were verbally informed of the procedures, but there was no written policy in place. This lack of clear procedures and staff training contributed to the failure to prevent the resident's elopement and ensure their safety.
Failure to Provide Medically-Related Social Services and Follow-Up
Penalty
Summary
The facility failed to ensure that medically-related social services and follow-up were provided to address guardianship, patient advocacy, and care planning reviews for a resident. The resident, who had diagnoses including dementia with behavioral disturbances and a history of traumatic brain injury, exited the facility without staff knowledge and was missing for four and a half hours. Upon return, the resident was given a wanderguard bracelet, but there was no documentation of a care planning review or guardianship status in the resident's records at the time of admission. The facility's Social Services Manager job description required the assessment and evaluation of each resident's psychosocial needs, incorporation of social service goals into the resident's plan of care, and completion of any required guardianship paperwork. However, the facility did not have a full-time social services staff since the previous social worker resigned in February, and the regional corporate social worker was only present once a week. This lack of consistent social services oversight contributed to the failure to identify and document the resident's legal guardianship status. The Administrator acknowledged that the resident's guardianship status should have been reviewed during care planning sessions, which were supposed to occur quarterly. However, there was no documentation of any care planning review for the resident since their admission. The Administrator also noted that the resident's guardianship paperwork was not reviewed upon admission, leading to the resident being incorrectly considered able to leave the facility on their own. This oversight resulted in the resident's elopement and subsequent placement on elopement risk protocols only after the incident occurred.
Failure to Address Nutritional Needs and Monitor Weight
Penalty
Summary
The facility failed to timely identify and address the nutritional needs and monitor the weights of a resident admitted with higher risk, resulting in decreased intake, significant undetected weight loss, and overall decline in status. The resident, who had diagnoses including respiratory failure, pneumonia, congestive heart failure, and COPD, was admitted for a short-term stay. Despite being identified as malnourished with a Mini Nutritional Assessment score of 6, the resident did not receive the recommended nutritional supplement, and their weight was not monitored as required. The resident's weight records showed a significant weight loss of 18.2 lbs over 25 days, with no monitoring of weights in between despite identified risks. The food acceptance record indicated that the resident frequently ate less than 50% of their meals or refused meals altogether. There was no follow-up by the Registered Dietician throughout the resident's stay, and the attending physician or their practitioner did not follow up on the resident's nutritional status or the ordered laboratory tests. Interviews with facility staff, including the Registered Dietician, Nurse Practitioner, and Director of Nursing, revealed inconsistencies and failures in the weight monitoring process and follow-up on the resident's nutritional needs. The facility's weight monitoring policy was not adhered to, and the resident's significant weight loss and malnourishment were not addressed in a timely manner, leading to the resident's overall decline in health status.
Inadequate Infection Control Program Leading to Hospitalization
Penalty
Summary
The facility failed to ensure a comprehensive infection control program that consistently identified infections based on symptoms and justified the use of antibiotics, as well as calculated infection rates, demonstrated ongoing tracking, trending, in-services, education, and environmental rounding. This deficiency resulted in a resident developing a change of condition leading to hospitalization due to a urinary tract infection. The complaint revealed that the resident was transferred to the hospital after a family member identified the change in their condition, and the resident was admitted to the hospital with a urinary tract infection and later readmitted to the facility. During the survey, it was found that the Director of Nursing (DON) was overseeing the infection prevention and control program but had not completed the necessary training or certification. The facility's MDS coordinator, who was a certified infection preventionist, was identified later and began reviewing charts for residents on antibiotics. However, the facility's infection control documents lacked calculated infection rates, trending, and environmental rounding/audits. The facility's infection prevention and control program policy indicated that the designated infection preventionist is responsible for oversight, but the program was not fully implemented as required, leading to the identified deficiency.
Failure to Timely Resolve Resident Grievance
Penalty
Summary
The facility failed to follow up and resolve a grievance in a timely manner for a long-term resident, resulting in feelings of frustration. The resident, who had diagnoses including congestive heart failure, metabolic encephalopathy, and breast cancer, reported waiting for almost three hours for a brief change after activating their call light. The incident occurred during the day shift, and the resident did not receive any follow-up from the facility administration despite the issue being brought to their attention by staff members. Interviews with various staff members, including a CNA, an LPN, and the Director of Nursing (DON), confirmed the resident's account of the incident. The DON stated that the facility's grievance process involves providing a grievance form and assisting residents or family members in filling it out if needed. However, no grievance form was initiated for this incident until 14 days later, after the concern was brought to the attention of the facility administrator and DON. The facility's follow-up included educating the CNA involved, but the education documentation did not specifically address the incident reported by the resident. The grievance form provided by the facility was dated 14 days after the incident, and the staff education focused on general CNA documentation and rounding procedures rather than the specific grievance. This lack of timely and specific follow-up contributed to the resident's frustration and the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarkston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lourdes Rehabilitation And Healthcare Center | 3.1 mi | — | 0 | 0 |
| Wellbridge Of Clarkston | 3.3 mi | — | 2 | 0 |
| Regency At Waterford | 3.3 mi | — | 2 | 0 |
| The Orchards At Canterbury On The Lake | 3.5 mi | — | 5 | 0 |
| The Villa At Silverbell Estates | 4.1 mi | — | 2 | 0 |
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