Pine Creek Manor Skilled Nursing & Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 8:50 AM an interview with Dietary Manager (DM) E regarding date marking found a receive date and open date should be marked on food items. On 04/28/2026 at 8:52 AM observed cut carrots wrapped in plastic with a facility marked date of 4/15 in the two-door refrigerator located in the dry storage room. Further observation found chopped carrots wrapped in plastic with a number four written on the outside. DM E discarded the items. On 04/28/2026 at 8:54 AM observed two containers of sliced tomatoes in plastic packages with no facility marked date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/28/2026 at 10:20 AM observed a hand sink with an inoperable hot water faucet in the laundry washing room. An interview with Laundry Aid (LA) H at this time found staff do not use the sink, and it has no warm water. On 04/28/2026 at 10:24 AM observed a utility sink located next to the hand sink in the laundry washing room with linens piled inside the basin. An interview with LA H at this time found the sink is not used, and the basin is used to store rags. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 04/28/2026 at 9:44 AM observed a mop sink in the soiled linen room with the hot water faucet missing. When the cold water faucet was turned on, water was observed leaking from the vacuum breaker. On 04/28/2026 at 9:49 AM observed the two-compartment utility sink in the soiled linen room with a chemical pre-dispensing system in place and the faucet left on. This set up puts undue back pressure on the faucet's internal atmospheric vacuum breaker (AVB), which can compromise the integrity of the mechanism. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to formulate an Advance Medical Directive (AMD- the written instruction relating to the provision of health care) for one (R7) of five residents reviewed for Advance Directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan that includes and supports the dementia care needs for one (R7) of one resident reviewed for care planning resulting in the potential to limit R7's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in 10 (102, 103, 107, 109, 110, 111, 112, 113, 116, and 117) resident Medicare or Medicaid rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned before stacking; 2. Properly date-label and store food in the kitchen; and 3. properly store ladles. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a urinary catheter drainage bag was maintained in a dignified manner for one resident (R97) of two residents reviewed for urinary catheters and dignity covers, resulting in the potential for embarrassment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an indwelling foley catheter was secured for one resident (R37) of two residents reviewed for catheter care with the potential to cause irritation and/or trauma.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure professional standards of practice for oxygen administration for one (R7) of one resident reviewed for oxygen administration resulting in a R7 receiving supplemental oxygen therapy without a healthcare provider order.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide 80 square feet of space per resident in three resident rooms resulting in the potential interference with care provided and resident dissatisfaction with their living environment.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for the facilities census of 40 residents and its staff resulting in an increased chance of harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergency or routine care and unmet care needs that could cause negative outcomes, affecting all 40 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide intact linen for three residents (R13, R28, and R9) of 10 residents reviewed for bed linen, resulting in a less than optimal homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to revise/update a care plan for one resident (R6) out of two residents reviewed for skin conditions, resulting in the potential for lack of skin treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an appropriate outlet extender for durable medical equipment (oxygen concentrator) was used for one resident (R31) of five residents reviewed for accidents, resulting in the potential for nonfunctioning medical equipment and an unsafe electrical connection.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently post nurse staffing information that was readily accessible for all 40 residents as well as visitors and vendors in the facility, resulting in necessary staffing information not being available to residents and visitors.

Inspectors wroteBased on observation and record review, the facility failed to provide 80 square feet of space per resident in 10 of 15 multiple resident rooms resulting in potential interference with care provided and resident dissatisfaction with their living environment.