Pine Creek Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety was maintained, when:1. An opened package of mozzarella cheese had blue and fuzzy spots; and2. One dietary staff had facial hair and did not fully cover with facial hair restraint. These failures had the potential to cause food-borne illness which could cause illness in 93 out of 93 medically vulnerable residents who consumed food from the facility kitchen. The census was 93.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record) for two of four randomly selected residents (Residents 44 and Resident 51). This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu or spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) was followed for the therapeutic diet during lunch on 6/16/26 and 6/17/26, when:A. During a dining observation on 6/16/26, Resident 105 did not receive a wheat roll with her lunch meal; andB. During a meal service distribution on 6/17/26:Three residents (Resident 32, 59 and 73) with renal and renal combination diets received extra portion of meat (protein) on the tacos;Four residents (Resident 9, 54, 77 and 107) with modified texture diets did not receive appropriate modified texture black beans; andTwo residents (Resident 54 and 77) with large portion diet received 1.5 servings [6 ounces (oz.)] of zucchini instead of one serving (4 oz.). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care consistent with professional standards of practice was provided for one of 25 sampled residents (Resident 2), when the continuous positive airway pressure (CPAP, a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure) daily equipment cleaning was done as ordered. This failure had the potential to result in the buildup of bacteria, mold and allergens which could lead to respiratory-related complications and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 25 sampled residents (Resident 96) was free of a significant medication error, when Taltz (a medication that stops swelling and inflammation caused by arthropathic arthritis (a type of arthritis that develops in people who have psoriasis [a skin condition causing itchy, scaly patches] when the immune system attacks healthy joints, causing them to become painful, swollen, and stiff) was not available for routine administration. This failure resulted in Resident 96 experiencing severe itching and discomfort, inability to sleep and psychosocial (the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm when his arthropathic psoriasis was left untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for three out of eight sampled residents (Resident 5, Resident 6, and Resident 7) when:1. Resident 5 and Resident 6's call light buttons were not within their reach; and,2. Resident 7's call light system was broken and was not provided with an alternative call system. This failure placed Resident 5, Resident 6, and Resident 7's safety at risk and had the potential for the residents' needs not to be met.

Inspectors wroteBased on interview and record review, the facility failed to follow the discharge process for one of three sampled residents (Resident 1), when Resident 1 was transferred to an acute hospital and Resident 1's Responsibility Party (RP) was not informed of intent to discharge the resident or provided with notice of bed-hold. This failure resulted in Resident 1 being denied return to the facility causing disruption of care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for three (3) of 27 sampled residents (Resident 82, Resident 25 and Resident 67) according to accepted standards of clinical practice when: 1. Resident 82's order for Thrombo-Embolic Deterrent, (TED stockings, also known as anti-embolism stockings, to prevent blood clots and swelling in the legs, particularly after surgery) and lymphatic compression device (devices that work by inflating sleeves around the legs to mimic muscle contractions, helping blood flow back to the heart) were not applied as ordered; and, 2. Resident 25 and Resident 67's TED hose were not applied as ordered. This failure decreased the facility's ability to provide a clear and consistent picture of the residents's conditions, treatment responses, outcomes, and risk factors to improve residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two (2) of 27 sampled residents (Resident 30 and Resident 38) proper hygiene when: 1. Resident 30 and Residents 38's fingernails were untrimmed, jagged and had black substances underneath the nailbeds; 2. Resident 30's skin on right foot was dry and scaly; 3. Resident 38's skin on right and left feet were dry and scaly; and, 4. Resident 30 and Resident 38's traced of colored-liquid, old and dry food residue stacked in between their beards. This failure decreased the facility's ability to maintain Resident 30 and Resident 38's overall health, comfort, and a sense of dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (medications that the use and possession of are controlled by the federal government) for three residents (Resident 30, Resident 38, and Resident 51) of a census of 95 were accurately accounted for on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) and Controlled Drug Record (CDR - a log for tracking dispensing of controlled substances to ensure compliance with relevant regulations). This failure decreased the facility's potential to ensure accurate accountability for residents' controlled medications and prevent their misuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that: 1. Discontinued medications were not available for resident use; 2. Medications were stored locked in medication cart; and, 3. Medications were stored in original packaging with pharmacy approved labels. These deficient practices had the potential for unsafe medication storage and administration for a census of 95.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient hydration for four residents (Resident 13, Resident 298, Resident 299, Resident 300) of a census of 95, when staff did not deliver bedside water pitchers for two days. This failure had the potential to cause dehydration (a harmful reduction in the amount of water in the body) to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document and secure the care and treatment provided for five of 27 sampled residents (Resident 82, Resident 25, Resident 67, Resident 249, and Resident 48) when: 1. Licensed Nurse 4 (LN4) documented she had applied Resident 82's Thrombo-Embolic Deterrent, (TED stockings, also known as anti-embolism stockings, designed to prevent blood clots and swelling in the legs, particularly after surgery) and lymphatic compression device (helps the trapped lymph fluid to move and flow through the lymph vessels) when she had not; 2. Resident 25 and Resident 67's administration records indicated TED hose had been applied daily by the LNs, when LN's had not; 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a Care Plan (CP, a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive) for one out of 27 sampled residents (Resident 79). This failure had the potential for Resident 79 to not receive the highest practible level of care for her health and wellness.

Inspectors wroteBased on observation, interview and record review the facility failed to provide one resident out of 27 sampled residents (Resident 79) with appropriate supervision and assistance during meals. This failure had the potential for Resident 79 to experience malnutrition and an increased risk of choking during meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet food storage and service practices that met professional standards for food service safety when: 1. There were opened food packages found with no opened date label; 2. There were foods found removed from their original packaging without labels; 3. There was food stored in unsealed packaging; and, 4. The sanitizer solution was below the effective range. These failures decreased the facility's potential to prevent food borne illness for 89 residents who ate facility prepared foods.

Inspectors wrote3. During a medication administration observation on 4/17/24 at 8:52 a.m., near room [ROOM NUMBER], a posted sign on the wall indicated, .Enhanced Standard Precautions .EVERYONE MUST: Perform hand hygiene before entering the room . The Licensed Nurse (LN) 1 was observed to prepare Resident 5's antibiotic medication to be administered via a peripherally inserted central catheter (PICC, a long, thin invasive tube inserted through a vein in the arm and passed through to the larger veins in the heart), entered room [ROOM NUMBER], and donned PPE without performing hand hygiene. The LN 1 grabbed two paper towels from the wall dispenser, set them on a side table and set the intravenous (IV) medication and equipment on top of the paper towels, without disinfecting the side table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate assessments for two residents (Resident 15 and Resident 301) of 24 sampled residents when: 1. Resident 15's Minimum Data Sheet (MDS, an assessment tool) indicated one side lower extremity impairment; and, 2. Resident 301's MDS indicated intermittent catheterization (a catheter used drain urine from the bladder on a temporary basis). These failures resulted in inaccurate assessments that did not reflect the residents' status and care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement an accurate baseline care plan for three residents (Resident 297, Resident 301 and Resident 307) out of 24 sampled residents when: 1. Resident 297's and Resident 301's did not have a care plan for their urinary catheter; and, 2. Resident 307 did not have a care plan for his urinary catheter, peripherally inserted central catheter (PICC, a long, thin tube inserted through a vein in the upper arm and passed through to the larger veins near the heart, used for long term fluids or treatments), abdominal binder (a wide compression belt that encircles the abdomen) and thrombo-embolic deterrent hose (TED hose, stockings used to help prevent blood clots and swelling in the legs). These failures decreased the facility's potential to implement effective, person-centered care for residents.

Inspectors wroteBased on observation, interview and record review the facility failed to revise a care plan for one resident (Resident 310) out of 24 sampled residents when Resident 310's care plan was not updated to reflect the placement of an elopement management bracelet (a bracelet that triggers alarms on doors to prevent the resident leaving unattended). This failure decreased the facility's potential to provide consistent nursing interventions for residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure services provided met nursing professional standards for two residents of 24 sampled residents when: 1. Resident 307's physician's order was not implemented for the use of thrombo-embolic deterrent hose (TED hose, stockings used to help prevent blood clots and swelling in the legs) and an abdominal binder (a wide compression belt that encircles your abdomen) to prevent orthostatic hypotension (low blood pressure which occurs when changing position from sitting or lying down to standing up); 2. Resident 307's peripherally inserted central catheter (PICC, a long, thin tube inserted through a vein in the upper arm and passed through to the larger veins near the heart, used for long term fluids or treatments) was not assessed for patency and covered with an appropriate dressing; and, 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 28) of 24 sampled residents was assisted to an upright position while eating lunch. This deficient practice decreased the facility's potential to prevent food aspiration (breathing food and fluid into the lungs) and aspiration pneumonia (severe infection of the lungs) for Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs were properly labeled for a census of 91 residents when a medication stored in a medication cart did not have an identification label. This failure reduced the facility's potential to ensure safe medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided by the facility met professional standards of practice for one of six sampled residents (Resident 1) when: 1. A physician's (MD) order for carbidopa-levodopa (an anti-Parkinson's medication) 25-100 mg. (milligrams, a unit of measurement) tablet, 1 tablet every 6 hours was discontinued on 6/23/23 at 6:32 a.m., and not reordered until 6/23/23 at 12 p.m., causing Resident 1 to go without a dose of her medication for 11 hours; and, 2. One dose of the medication on 6/22/23, two doses of the medication on 6/25/23, and one dose on 7/1/23 were administered late. These failures had the potential to result in Resident 1 suffering negative side effects of the missed and late doses such as worsening tremors, increased rigidity and pain.