Allure of Pinecrest

Inspectors wroteBased on interview and record review the facility failed to document resident assessments for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3.

Inspectors wroteBased on interview, and record review the facility failed to provide documentation showing staff was qualified to replace a gastrostomy tube (g-tube) per standards of practice for 1 of 4 residents (R1) reviewed for staff qualifications in the sample of 4. This failure resulted in R1's g-tube migrating into the small intestines leading to complications requiring hospitalization. Findings Include: On 4/13/26 at 12:10 PM, V1 (Administrator) said she did not know if V2 had any certification or training on changing a urinary catheter g-tube and to ask V2 directly. On 4/13/26 at 12:16 PM, V2 (Director of Nursing/DON) said she was not sure what prompted R1's urinary catheter g-tube to be changed, the nurse approached her and said the family wanted her to change it. V2 said it was a routine procedure, a standing order, and she didn't speak with V10 (R1's Physician). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor a urinary catheter gastrostomy tube (g-tube) placement, failed to have policies in place for the care of a urinary catheter g-tube, and failed to have polices in place for replacing a urinary catheter g-tube for 1 of 2 residents (R1) reviewed for gastrostomy tubes in the sample of 4. This failure resulted in R1's being hospitalized due to her gastrostomy tube advancing into her small intestine causing a partial small bowel obstruction and pancreatitis. Findings Include: On 4/9/26 at 10:09 AM, V13 (R1's son) said after R1's g-tube was replaced, the tube was leaking. The only part of the tube sticking out of R1 was the nipple on the end. V9 and V2 were at the bedside looking at R1's g-tube. V2 asked him if he did this, which he told her no. Shortly after R1 was sent to the emergency room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings Include:On 4/9/26 at 12:14 PM, V3 (Certified Nursing Assistant/CNA) said R1 is alert to self only and is dependent on staff for all care. V3 said R1 is nonverbal and cries out often. V3 said R1 is incontinent of bowel and bladder. On 4/9/26 at 12:22 PM, R1 was sitting in a wheelchair in the nurses' station. R1 was alert and looking around the room but did not respond when spoken to. On 4/9/26 at 2:16 PM, V6 (CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of abuse to the state agency for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings Include:On 4/9/26 at 2:16 PM, V6 (Certified Nursing Assistant/CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but was not sure who. V6 said it is not appropriate to talk to residents that way. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of verbal abuse was investigated for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. Findings Include: On 4/9/26 at 2:16 PM, V6 (Certified Nursing Assistant/CNA) said she asked V7 (Licensed Practical Nurse/LPN) to help her change R1 who had been incontinent of stool. V6 said they both entered the room together and V7 was not aware that V13 (R1's son) was sitting in the corner of the room. V6 said V7 spoke out loud, this sh*t is getting old, here we go again, you are acting like a child. I should leave you here naked. V6 said V7 was inappropriate and said things that she wouldn't say to her own child. V6 said she talked to someone about it that day but could not recall whom. V6 said it is not appropriate to talk to residents that way. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessed elopement interventions were in place for 3 of 3 sampled residents (R1, R2, R3) at risk for elopement and failed to ensure the elopement alert system was implemented at exit doors in resident areas. These failures resulted in R1 exiting through a resident wing door on 3/26/26 at 5:35 AM and found by staff at 5:38 AM walking outside in the dark approximately 50 feet down the facility's sidewalk with a slope to the right side, without a walker, and without wearing her elopement alert bracelet or temperature appropriate clothing.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a cognitively impaired resident from leaving the facility unsupervised for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's medical record contained documentation of a change of condition for 1 of 3 residents reviewed for medical record accuracy in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to notify the wound care provider of a resident's critical lab value prior to wound care. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety and supervision was maintained for 2 of 3 residents (R1, R2) reviewed for elopement in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed pork was pureed to a pudding-like consistency. This applies to 4 of 4 residents (R390, R60, R339, R1) reviewed for pureed diets in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were issued an advanced beneficiary notice form. This applies to 3 of 3 residents (R9, R83, and R289) reviewed for beneficiary notices in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) assistance was provided for a dependent resident for 1 of 19 residents (R40) reviewed for ADLs in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate a pre-surgical order for a resident prior to his abdominal surgery. The facility failed to implement treatment orders for a resident with compression fractures of her spine. These failures apply to 2 of 19 residents (R43 and R390) reviewed for quality of care in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner for 2 of 19 residents (R30 and R40) reviewed for safety and supervision in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (R73 and R76) reviewed for dementia care in the sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to address an irregularity found by the pharmacist during the monthly medication review for 1 of 5 residents (R73) reviewed for drug regimen review in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's medication labeling was legible for 1 of 19 residents (R32) reviewed for medication storage and labeling in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions for 1 of 19 residents (R63) reviewed for infection control in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 2 of 3 residents (R2 and R3) reviewed for infection control in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to obtain the necessary weights on residents (R1, R5) with diagnosis of congestive heart failure (CHF). The facility failed to obtain and complete the necessary lab work on resident (R1) with diagnoses of CHF and chronic kidney disease. These failures contributed to R1 being re-hospitalized with diagnoses of fluid overload and an exacerbation of CHF. These failures apply to 2 of 5 residents (R1, R5) reviewed for necessary care and services in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 2 of 13 residents (R12 & R14) reviewed for dignity in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 3 residents (R1) reviewed for dignity in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to assess and monitor a resident that experienced a change in condition and failed to implement interventions as ordered by the physician resulting in the death of one of 18 residents (R93) reviewed for quality of care in the sample of 18. The Immediate Jeopardy began on April 27, 2024 at 11:00 AM when V9 CNA (Certified Nursing Assistant) reported a change in condition to V10 LPN (Licensed Practical Nurse) and V10 instructed V9 to wait until R93's lunch tray arrives. V1 Administrator was notified of the Immediate Jeopardy on May 9, 2024 at 11:08 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on May 10, 2024 at 10:00 AM, but non compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the inservice training.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nutritional supplements as ordered for one of three residents (R64) reviewed for weight loss in the sample of 18. This failure contributed to R64 experiencing a 11.41% weight loss in the last six months.

Inspectors wrote4. R194's Physician's Order Sheet printed on 5/7/24 shows an order for Lorazepam 0.5 milligrams (mg)-Give 1 tablet by mouth every 12 hours as needed for anxiety. The order had a start date of 4/19/24 and there was no end date documented. Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications had a duration for 5 of 5 residents (R40, R26, R50, R28, R194) reviewed for psychotropic medications in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and implement interventions for a known contracture for 1 of 2 residents (R13) reviewed for range of motion in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was safely transferred with a sit to stand lift for 1 of 18 residents (R14) reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's head remained elevated above 30 degrees while a tube feeding was infusing for 1 of 1 residents (R393) reviewed for tube feedings in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore isolation gowns when providing high contact care to a resident on enhanced barrier precautions for 1 of 18 residents (R393) reviewed for infection control in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's safety while using a mechanical stand lift machine for 1 of 3 residents (R1) reviewed for safety in the sample of 6. This failure resulted in R1 having a decline in the ability to raise her left arm, and R1's Physician diagnosing R1 with a complete rotator cuff tear.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report a resident injury to the state agency for 1 of 3 residents (R1) reviewed for injuries in the sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident (R12) with a change of condition was assessed and monitored after exhibiting an altered mental status. This failure resulted in R12 being admitted to the hospital with, hypoglycemia and sepsis related to a UTI (urinary tract infection). The facility also failed to ensure a resident received x-ray services without any delay for R57 following a fall. This failure resulted in R57 waiting 18 hours for an x-ray, and the x-ray showed a fractured hip requiring surgical intervention. This applies to 2 of 2 residents (R12, R57) reviewed for quality of care in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a pressure injury before becoming a Stage 2 or greater and failed to provide initial wound assessments for 2 of 4 residents (R14, R5) reviewed for pressure injuries in the sample of 18. This failure resulted in R14 developing two Stage 2 and one Stage 3 pressure injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify, implement, and document control measures to prevent the growth of opportunistic waterborne pathogens (such as Legionella); failed to establish acceptable ranges for control measures; and failed to identify corrective actions for when control limits are not met. This applies to all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medication administration was observed for 1 of 1 resident (R20) reviewed for medication administration in the sample of 18 and 3 residents (R66, R48, R6) outside of the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an at-risk resident with a history of falls was safe by not providing supervision to prevent falls for 1 of 8 residents (R40) reviewed for falls in the sample of 18.