Provider Name: PINE MEADOWS HEALTH CARE
Address: 700 NUCKOLLS ROAD, BOLIVAR, TN 38008
Phone: (731) 658-4707
County: Hardeman (340)
Ownership Type: For profit - Corporation
Certified Beds: 134
Average Residents Per Day: 95.3 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: BOLIVAR OPERATOR LLC
First Approved Date: September 6, 1989
Affiliated Entity: PRESTIGE ADMINISTRATIVE SERVICES (416)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 4 ()
Health Inspection Rating: 4 ()
QM Rating: 2 ()
Long Stay QM Rating: 3 ()
Short Stay QM Rating: 1 ()
Staffing Rating: 2 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.13873, LPN Staff Hours Per Day: 1.1796, RN Staff Hours Per Day: 0.4317, Licensed Staff Hours Per Day: 1.6113
Total Nurse Staff Hours Per Day, per resident: 3.75010
Weekend Nurse Staff Hours: 2.89160, Weekend RN Staff Hours: 0.1304
PT Staff Hours Per Day, per resident: 0.0415
Nurse Staff Turnover: 52.3, Nurse Turnover Note:
RN Turnover: 64.3, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2754, Case Mix LPN Hours Per Day: 0.7790, Case Mix RN Hours Per Day: 0.4184
Adjusted Nurse Aide Hours Per Day, per resident: 1.91482, Adjusted LPN Hours Per Day: 1.1174, Adjusted RN Hours Per Day: 0.3887
Total Adjusted Nurse Hours Per Day, per resident: 3.40354
Adjusted Weekend Nurse Hours Per Day, per resident: 2.62438
Health Survey Dates and Scores: Cycle 1: 2021-06-10 (Score: 20), Cycle 2: 2020-03-12 (Score: 0), Cycle 3: 2019-04-11 (Score: 4)
Total Weighted Health Score: 10.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 3250.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 700 NUCKOLLS ROAD,BOLIVAR,TN,38008 (35.2690, -89.001)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-15
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-15
Type: Health, Deficiency: Ensure that residents are free from significant medication errors.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-15
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-15
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-07-15
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-29
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-04-24
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-05-03
Type: Fire Safety, Tag: 0923, Version: New
Description: Have proper medical gas storage and administration areas.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-04-22