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Pine Acres Rehab: Medication Error Violations - IA
Resident #3 arrived at the hospital on September 5, 2025, with both patches still attached to her body....
Latest reports, citations, and penalties from CMS data
Resident #3 arrived at the hospital on September 5, 2025, with both patches still attached to her body....
But the abuse allegation didn't reach facility administrators until October 13....
Federal inspectors discovered the dangerous storage violation on October 22 during a complaint investigation at the facility on North West Street....
The facility's Activity Director acknowledged the practice during an interview with inspectors on November 20....
The resident, identified in inspection records only as R1, was transferred to the facility's rehabilitation unit after a hospital stay in early August 2025....
The failures affected a small number of residents....
Two separate care plans also required weight monitoring....
According to the facility's Director of Nursing, Resident #4 placed his hands on the back of Resident #2's wheelchair, prompting her to yell at him to stop....
The resident, identified in inspection records as R1, had suffered a displaced intertrochanteric fracture of the right femur before arriving at the facility....
She sent the wrong medical record....
Resident 35 has severe cognitive impairment, scoring just three out of 15 points on a mental status assessment....
The inspection, completed December 1, 2025, flagged the practice under infection control standards and identified many residents as affected....
The medication errors at Dells Nursing and Rehab Center went undetected until federal inspectors arrived in late October following a complaint....
Inspectors documented the sequence during a complaint investigation completed November 25, 2025....
The citation was one of **two deficiencies** documented during the inspection....
The deficiency was classified at **Scope/Severity Level D**, meaning it was isolated in nature and did not result in documented actual harm....
The facility has not submitted a plan of correction for the cited violations....
Resident 221 was admitted with chronic respiratory failure, morbid obesity, and sleep apnea....
The facility's Director of Nursing performed the admission skin assessment and found an open area on the resident's sacrum and coccyx....
Staff discovered the assault at 8:00 p.m....