Pine Run Lakeview.

“Two residents discharged from the home did not receive refunds within the required 30 days. The home did not provide itemized written accounts and refunds in a timely manner.”

“Staff person B did not receive training in fire safety completed by a fire safety expert or by a staff person trained by a fire safety expert during the 2024 training year.”

“Laptop screen, empty medication packets, and report sheets containing resident information were left unlocked, unattended, and accessible on the second floor medication station by staff member A at 10:00 a.m.”

“The fire extinguisher in the commercial laundry has not been inspected by a fire safety expert since January 2024, in violation of the annual inspection requirement.”

“Fire drill records for multiple dates (7/16/25 missing time; 8/31/24 through 7/16/25 missing exit route information) do not include all required information.”

“The last fire drill conducted during sleeping hours was on 1/17/2025 at 3:27 a.m., and no sleeping hours drill was conducted within the required 6-month period.”

“Exit doors leading to the Memory Care courtyard were locked and accessible only to staff with a key, blocking egress and creating a safety hazard in emergency situations.”

“Resident requiring supervision outside the home eloped from the secured dementia care unit through an unlocked courtyard gate following a fire drill. The resident exited onto a nearby two-lane highway after the courtyard gate was not physically closed following the emergency evacuation.”

“During a fire drill, a resident with cognitive impairment, hearing loss, and orientation only to person and time was able to elope from the facility through an unsecured gate onto a nearby highway with 35 mph speed limit. The resident fell on the roadway and was endangered by vehicular traffic during the incident.”

“Staff member used profane language directed at a resident and made derogatory comments about the resident in the resident's presence, including stating the resident is 'annoying' and was 'up all night,' failing to treat the resident with dignity and respect.”

“Fire drill logs showed the facility routinely evacuated secured dementia care unit residents to the living/activity room only, rather than using alternate exit routes as required during fire drills.”

“An alleged abuse incident involving a resident and staff person was not reported to the department within 24 hours as required. The facility failed to timely report the incident to the Department's personal care home regional office or complaint hotline.”

“Multiple medication storage and documentation errors were identified including: a transcription error on a declining inventory log, a glucometer not calibrated to correct time, and multiple glucometer readings not documented or incorrectly documented on Medication Administration Records.”

“A resident with an order to have readings checked twice daily did not register a reading on a specific date, but a level was still documented on the Medication Administration Record without obtaining the actual result.”