Pine Creek Rehabilitation and Nursing

Inspectors wroteBased on interview and record review, the facility did not use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Specifically, the facility did not always have a registered nurse at least 8 consecutive hours on certain weekends. Findings Included: Findings Included:The facility's staffing schedules from September 2025 to October 2025 were reviewed.-There was no RN scheduled on 9/14/25.-There was no RN scheduled on 9/28/25. On 10/8/25 at 2:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they did not need to have a registered nurse scheduled on every shift. The DON stated that they did not do admissions on the weekends and if the residents needed an assessment completed the nurse would call her. On 10/8/25 at 3:21 PM, an interview was conducted with the Administrator (Admin). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident's transfer or discharge was documented in the resident's medical record and the information was communicated to the receiving provider to ensure a safe and effective transition of care. Specifically, for 3 out of 23 sampled residents, the resident's medical record did not contain documentation of what information was sent to the receiving provider and the transfer or discharge was not documented. In addition, a resident that was discharged to the hospital was not provided with a bed hold notice. Resident identifiers: 31, 33, and 38.

Inspectors wroteBased on interview and record review, for 3 out of 23 sampled residents, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, blood pressure medications were administered outside of the physician's ordered parameters. Resident identifiers: 1, 4, and 6.

Inspectors wroteBased on interview and record review, the facility did not prevent misappropriation of a resident's property. Specifically, for 1 out of 23 sampled residents, a resident gave a Nursing Assistant (NA) money and the NA did not return the money when the resident asked for the money back. Resident identifier: 38.

Inspectors wroteBased on interview and record review, the facility did not ensure all alleged violations involving abuse, including misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, to Adult Protective Services (APS) and local law enforcement. Specifically, for 1 out of 23 sampled residents, an allegation of misappropriation of resident property was not reported to law enforcement and the report to APS was reported 17 days after the allegation. Resident identifier: 38.

Inspectors wroteBased on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident with a referral to see a neurologist for evaluation was not completed. Resident identifier: 14.

Inspectors wrote2. Resident 87 was admitted to the facility on [DATE] with diagnoses which included diffuse traumatic brain injury, vascular dementia, traumatic hemorrhage of cerebrum atrial flutter, atrial fibrillation, anxiety disorder, generalized muscle weakness, other lack of coordination, cognitive communication deficit, other toxic encephalopathy, unsteadiness on feet, essential hypertension, hyperlipidemia, hypermagnesemia, hypomagnesemia, insomnia, other symptoms and signs involving cognitive functions and awareness, other reduced mobility, and long term (current) use of anticoagulants. On 10/5/23 at 7:50 PM, a nursing progress note documented, CNA brought to nurses attention that patient had a fall from wheelchair. Head to toe assessment completed. Upon assessment, superficial laceration noted on top of scalp and abrasions on his back. Steri strips placed on laceration. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility failed to ensure that the resident had adequate supervision and assistance devices to prevent accidents. Specifically, a resident was not secured inside the facility vehicle during transport and fell out of her wheelchair. The fall resulted in the resident sustaining a Thoracic (T)11-T12 fracture and a contusion of the abdominal wall. Based on the facility's investigation and corresponding corrective measures, this was cited at past non-compliance with a correction date of 8/1/23. Resident identifier: 9.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident with a history of suicidal ideations (SI) was hospitalized for a suicidal attempt and did not have behavioral health services provided for more than 2 months after the hospitalization. Resident identifier 14.

Inspectors wroteBased on observation and interview, it was determined that for 3 of 28 sampled residents, that the facility did not treat each resident with respect and dignity. Specifically, staff at the facility were observed standing next to residents while assisting them with eating, staff were observed using labels instead of resident names when addressing residents, residents were not served meals at the same time, and residents did not receive necessary assistance during dining. Resident identifiers: 11, 18, and 19.

Inspectors wrote5. Resident 91 was admitted [DATE], readmitted [DATE], and discharged [DATE] with diagnoses including unspecified focal traumatic brain injury with loss of consciousness status unknown sequela, type 2 diabetes mellitus, chronic obstructive pulmonary disease, dementia, generalized anxiety disorder, and major depressive disorder. Resident 92 was admitted [DATE], discharged [DATE] with diagnoses including Alzheimer's disease, dementia, other psychotic disorder, mood disorder, unspecified psychosis, anxiety disorder, and major depressive disorder. Resident 2 was admitted [DATE], readmitted [DATE] with diagnoses including unspecified focal traumatic brain injury with loss of consciousness status unknown sequela, type 2 diabetes, chronic obstructive pulmonary disease, and dementia. [...]

Inspectors wroteBased on interview and record review it was determined, for 2 out of 28 sampled resident, that the facility did not ensure that all alleged violations involving abuse or injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, a resident had a newly identified bruise that was not reported to the SSA and an incident of verbal abuse by a Certified Nurse Assistant (CNA) towards a resident was not reported to APS. Resident identifiers 18 and 22.

Inspectors wroteBased on interview and record review it was determined, for 3 of 28 sampled residents, that the facility in response to allegations of abuse did not prevent further potential abuse while the investigation was in progress. Specifically, the facility did not put effective measures in place to ensure that abuse did not occur and corrective measure that were identified were not implemented. Resident identifier, 14, 85, and 86.

Inspectors wroteBased on interview and record review it was determined, for 4 out of 28 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the transfer or discharge was documented in the resident's medical record and that all the information was communicated to the receiving provider. The information provided to the receiving provider should include contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found to demonstrate what information was communicated to the receiving provider. [...]

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or included the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, in the medication refrigerator, one multi-dose vial was not labeled with an opened date, insulin pens did not have names or dates, one insulin pen was expired with an open date of [DATE], and a Prevnar 13 dose was expired and available to use.

Inspectors wroteBased on record review and interview, it was determined that for 2 of 28 sample residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, there were at least two instances where the facility did not obtain International Normalized Ratio (INR) labs for a resident despite there being physician orders for the labs to be obtained every 4 weeks and one instance where the facility did not obtain a Basic Metabolic Panel (BMP) for another resident despite there being physician orders for the BMP to be drawn. Resident identifiers: 31 and 9. Findings Included: [...]

Inspectors wroteBased on interview and record review, it was determined that for 1 out of 28 sampled residents, the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized and the facility kept confidential all information contained in the resident's records. Specifically, resident's information was left open on a computer screen unsecured on two different occasions while residents were in the vicinity and no documentation of a resident's hospital visit was found in the medical record. Resident identifier: 14.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the resident or resident representative had the opportunity to accept or refuse a COVID-19 vaccine, and that the resident's medical record included documentation that indicated that the resident was provided education regarding the benefits and potential risks associated with the vaccine; documentation of each dose administered; and documentation of declinations or contraindications to the vaccine. Specifically, for 4 out of 5 sampled residents, the facility did not have evidence that each resident was provided education about the COVID-19 vaccine, was provided the COVID-19 vaccine, or declined the COVID-19 vaccine. Resident identifiers: 7, 18, 28, and 30.

Inspectors wroteBased on interview and record review it was determined, for 2 of 28 sampled residents, that the facility did not immediately consult with the resident's physician and notify when there was an accident involving the resident which resulted in injury; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment, or a decision to transfer or discharge the resident from the facility. Specifically, a resident had an injury of unknown origin identified and the physician was not notified. Additionally, the physician was not notified when a resident refused blood draws for laboratory orders. Resident identifiers: 14 and 18.

Inspectors wroteBased on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, resident restrooms were found to be dirty and there were strong odors of urine in facility restrooms Findings Included: On 10/02/24 at 11:42 AM, an observation was made of the restroom located in room [ROOM NUMBER]. There was a stain surrounding the base of the toilet. On 10/02/24 at 11:45 AM, an observation was made of the restroom located in room [ROOM NUMBER]. There was a strong odor of urine. On 10/02/24 at 11:58 AM, an interview was conducted with the Housekeeper. The Housekeeper stated that the restroom in room [ROOM NUMBER] always smells like mold and mildew. The Housekeeper stated that she tries to get rid of the odor in the restrooms by scrubbing the toilet and shower with disinfectant. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 resident's sampled, that the facility did not implement written policies and procedures that ensure reporting of all alleged violations to the Administrator, State Survey Agency (SSA), and Adult Protective Services (APS). Specifically, an allegation of verbal abuse by a facility Certified Nurse Assistant (CNA) towards the resident was not reported to Adult Protective Services. Resident identifier 22.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that recommendations from the pre-admission screening and resident review (PASRR) level II determination and evaluation were implemented and included in the resident assessment, care planning and transitions of care. Specifically, a residents PASRR level II recommendations for specialized services for mental illness was not implemented. Resident identifier 14.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not provide routine and emergency drugs and biological to its residents. Specifically, a resident was not provided their psychotropic medications for multiple days due to unavailability from the pharmacy. Resident identifier: 9.

Inspectors wroteBased on interview and record review, it was determined that for 2 out of 28 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not monitor the blood sugars of a resident receiving insulin, did not administer a resident's thyroid medication, address a resident's continued pain, or use non-pharmacological pain interventions. Resident identifiers: 9, 32.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary psychotropic drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use. Specifically, a resident's psychotropic medications were not monitored for behavioral episodes, non-pharmacological interventions, and adverse side effects of the medications. Resident identifier: 9.

Inspectors wroteBased on observation, interview, and record review, it was determined for 2 out of 28 sample residents, that the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 27 medication opportunities, on 9/24/24, revealed two medication errors which resulted in a 7.41% medication error rate. Specifically, wrong doses of medications were given. Resident identifiers: 12, 31.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges, and only obtain laboratory services when ordered by a physician. Specifically, a resident's Basic Metabolic Panel (BMP) and lipid panel had results out of range and the provider was not notified and a BMP and lipid panel were obtained without a physician order. Resident identifier 14.

Inspectors wroteBased on record review and interview, it was determined that for 1 of 28 sampled residents that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, there were two instances where a resident had physicians orders for a residents lithium levels to be checked, but the results of these lithium level checks were not filed or uploaded in the resident's electronic medical record. Resident Identifier: 31. Findings Included: [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 28 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, a resident's 12 lead electrocardiogram (EKG) was not in the medical records. Resident identifier 14.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 2 of 28 sampled residents, that the facility did not ensure that each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, there were resident complaints about the food served at the facility, a test tray was pulled and found to be unappetizing, and there were resident council complaints regarding the food served at the facility. Resident Identifiers: 17 and 30. Findings Included: On 9/22/24 at 12:43 PM, Resident 17 was observed to complain that the lunchtime meal served was too cold during a lunchtime meal observation. At 12:46 PM, Resident 17 further complained that the food served would be good if it was warm. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the quality assessment and assurance committee met at least quarterly to coordinate and evaluate activities under the Quality Assurance and Performance Improvement (QAPI) program. The Quality Assessment and Assurance (QAA) Committee must be composed of, at a minimum: The Director of Nursing (DON); the Medical Director or his/her designee; at least three other members of the facility staff and one must be the Administrator; and the infection preventionist. Specifically, there was no evidence that the Medical Director participated in the quarterly QAPI meetings.

Inspectors wroteBased on observation and interview it was determined, for 2 out of 28 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, medications were not administered in a sanitary manner. Resident Identifiers: 12 and 25.

Inspectors wroteBased on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not establish an infection prevention and control program (IPCP) that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was receiving an antibiotic for a urinary tract infection and the facility did not follow up with the hospital for the culture and sensitivity results. Resident identifier: 19.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 28 sampled residents, that the facility did not ensure that any individual working in this facility working as a paid feeding assistant had completed a State-approved training program for feeding assistants. Specifically, a staff member who was not a Certified Nursing Assistant (CNA), a Licensed Nurse, or a paid feeding assistant assisted a resident with a feeding. Resident Identifier: 28. Findings Included: Resident 28 was admitted [DATE] with diagnoses including aphasia following cerebrovascular disease, other frontotemporal neurocognitive disorder, moderate protein-calorie malnutrition, vitamin B12 deficiency anemia unspecified, and dementia in other diseases classified elsewhere moderate with agitation. Resident 28's medical record was reviewed. [...]

Inspectors wroteBased on observation and interview, it was determined the facility failed to provide a clean and comfortable homelike environment. Specifically, a continuous high pitched alarm in the dining area, dirt and debris was observed on the resident room doors and bed rails, area of flooring and seating pads of chairs in the dining room were in disrepair, trash and debris blocked the air duct in the facility day room, a set of broken closet doors, and paint peeling from the walls in resident rooms. Residents identifiers: 4, 5, 16, 17, 20, 25, 29, and 30.

Inspectors wroteBased on record review and interview it was determined for 1 of 18 sample residents that the facility did not include provisions to inform and provide written information concerning the right to accept or refuse medical or surgical treatment and, at the residents' option formulate an advance directive. Specifically, one resident was not provided the opportunity to document his life-saving preferences. Resident identifier: 2.

Inspectors wroteBased on interview and record review it was determined, for 1 of 18 sample residents, that the facility did not coordinate assessments with the pre-admission. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, a resident with multiple falls was not provided an adequate walker, and a resident on supervised smoking was observed smoking outside without staff supervision. Resident identifiers: 29 and 31.

Inspectors wroteBased on interview and record review, it was revealed that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, two residents were receiving blood pressure medications outside of the ordered parameters and a resident had a medication held without orders to hold the medication. Resident identifiers: 19 and 30.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents medical records included documentation that indicated that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. Specifically, two residents did not have documentation in their electronic medical record indicating if they had or had not received the pneumococcal vaccine. Resident identifiers:

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents medical records included documentation that indicated that the resident either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindication or refusal. Specifically, one resident did not have documentation in their electronic medical record indicating if the facility offered a resident the COVID-19 vaccination. Resident identifier: 31 Findings Include: 1. [...]