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Inspection visit

Inspection

Pinewood Health and RehabilitationCMS #11560723 citations on this visit
23 citations recorded

Citations

23 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0584GeneralS&S Epotential for harm

    F584 - Safe Environment

    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  • 0623GeneralS&S Epotential for harm

    F623 - Transfer and discharge-

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625GeneralS&S Epotential for harm

    F625 - Transfer and discharge-

    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0758GeneralS&S Dpotential for harm

    F758 - Medication Errors

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  • 0914GeneralS&S Epotential for harm

    F914 - Be designed or equipped to assure full visual privacy for each

    Provide bedrooms that don't allow residents to see each other when privacy is needed.

  • 0880GeneralS&S Dpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0567GeneralS&S Dpotential for harm

    F567 - The resident has a right to manage his or her financial affairs

    Honor the resident's right to manage his or her financial affairs.

  • 0582GeneralS&S Bno actual harm

    F582 - The facility must—

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0583GeneralS&S Dpotential for harm

    F583 - Privacy and Confidentiality

    Keep residents' personal and medical records private and confidential.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • 0812GeneralS&S Fpotential for harm

    F812 - Food safety requirements

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0838GeneralS&S Fpotential for harm

    F838 - Facility assessment

    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

  • 0867GeneralS&S Fpotential for harm

    F867 - Program feedback, data systems and monitoring

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  • 0883GeneralS&S Dpotential for harm

    F883 - Influenza and pneumococcal immunizations

    Develop and implement policies and procedures for flu and pneumonia vaccinations.

  • 0004GeneralS&S Fpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0345GeneralS&S Fpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0351GeneralS&S Epotential for harm

    Install an approved automatic sprinkler system.

  • 0363GeneralS&S Dpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372GeneralS&S Dpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0511GeneralS&S Dpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0923GeneralS&S Dpotential for harm

    F923 - Have adequate outside ventilation by means of windows, or mechanical

    Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the November 22, 2019 survey of Pinewood Health and Rehabilitation?

This was a inspection survey of Pinewood Health and Rehabilitation on November 22, 2019. The surveyor cited 23 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Pinewood Health and Rehabilitation on November 22, 2019?

Yes, 23 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.