The Pines at Clarks Summit.

“The facility failed to report an incident within 24 hours. On 02/10/2026 at 9:30 a.m., the home became aware that a resident stated staff hit them, but did not report the incident to the department until 3:15 p.m. that day.”

“An egress route was obstructed and non-functional. At 9:20 a.m., the egress from the Memory Care courtyard did not open when the current keypad code was entered.”

“A resident with a history of physical altercations pushed staff and another resident to the ground, causing the resident to be hospitalized with a diagnosed injury. The facility failed to prevent neglect and physical harm to residents.”

“A resident's support plan was not updated to reflect aggression incidents that occurred on 7/4/25, 11/30/25, and 12/14/25, or the facility's plan to ensure the safety of all residents, despite the requirement to revise support plans as conditions change.”

“The egress from the memory care courtyard was obstructed with a wire bike lock securing the double doors, preventing unobstructed emergency evacuation.”

“An unmarked plastic container of margarine in the memory care kitchenette refrigerator was not labeled or dated as required for food storage.”

“A facility failed to report threatening comments made by Staff Person A toward a resident to the Department within the required 24-hour timeframe. The incident was not reported until after the 24-hour deadline.”

“Staff Person A made disrespectful and threatening comments toward a resident, stating in the resident's presence 'If slaps me one more time, I'm going to punch in the face,' failing to treat the resident with dignity and respect.”

“Emergency telephone numbers for the nearest hospital, police department, fire department, ambulance, poison control, local emergency management, and personal care home complaint hotline were not posted on or by the Memory Care Unit kitchenette landline phone.”

“A resident's annual medical evaluation was completed on an outdated form rather than the new Department-required form for Documentation of Medical Examination, effective as of a specified date.”

“A resident was self-administering a topical cream to apply bilaterally to toes twice daily without being assessed by a physician, physician's assistant, or certified registered nurse practitioner regarding the ability to self-administer as required.”

“Staff person B administered medication tablets at bedtime but failed to document administration on the Medication Administration Record (MAR). Staff person A then administered another dose, resulting in the resident receiving double the prescribed dose.”

“Due to failure to document medication administration, the resident received an additional dose of medication, which did not comply with the physician's prescribed directions for administration.”

“Two residents were injured in falls but incidents were not reported to the Department of Human Services within the required 24-hour timeframe. Both incidents occurred over weekends and there was miscommunication about who would be responsible for reporting.”

“The home did not have thermometers in refrigerators located in the Evergreen Secured Unit medication room and second floor medication room, which are required to ensure food is stored at safe temperatures.”

“The home's annual fire safety inspection and supervised fire drill was not completed within the required annual timeframe, delayed due to severe county flooding and the Fire Chief's unavailability.”

“The home did not have resident menus posted for the present week and upcoming week in the Evergreen Secured Unit at the time of inspection, as required to be posted one week in advance.”

“One resident's Vitamin D capsules with a September 2023 expiration date were found in the medication cart and had not been properly destroyed or removed, despite being identified by Med Techs as needing destruction.”