Pine Crest Health and Memory Care

Inspectors wroteBased on interview and record review, the facility did not have policies in place to provide residents a written notice of transfer to include reason for transfer, Ombudsman contact information, and appeal rights. This has the potential to affect all 93 residents. This is evidenced by:On 06/03/26, Surveyor requested the facility's transfer notice policy. Surveyor reviewed the facility's policy and noted no protocol to provide residents a written transfer notice that states the reason for the transfer, Ombudsman contact information, and appeal rights. On 06/03/26 at 2:51 PM, Surveyor interviewed Director of Nursing (DON) B regarding written transfer notices. DON B stated being unaware that there was a requirement to provide a written notice of transfer to residents unless they were being discharged .

Inspectors wroteBased on interview and record review, the facility did not provide residents a written notice of transfer that includes reason for transfer, Ombudsman contact information, and appeal rights to 10 of 10 residents (R7, R17, R8, R14, R99, R6, R83, R3, R96, and R101) reviewed. R7 was transferred to the hospital on [DATE]. A written notice of transfer was not completed. R17 was transferred to the hospital on [DATE]. A written notice of transfer was not completed. R8 was transferred to the hospital on [DATE]. A written notice of transfer was not completed. R14 was transferred to the hospital on 2/21/26. A written notice of transfer was not completed. R99 was transferred to the hospital on [DATE] and 04/15/26. A written notice of transfer was not completed. R6 was transferred to the hospital on 2/25/26. A written notice of transfer was not completed. [...]

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 93 of 93 residents.-Surveyor observed an opened bag of cauliflower and an open bag of chopped celery were not dated with an expiration date, an open date, or a use by date.-Surveyor observed several individual uncovered bowls of lettuce without a date identifying when they were prepared. -Surveyor observed several uncovered prepared desserts without a date identifying when they were prepared.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 93 residents (R.) -The facility's measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems are not being performed based on nationally accepted standards and in accordance with their Water Management Program and the facility does not demonstrate they have system in place to monitor the control measures as indicated. -The facility did not disinfect equipment used during wound cares for R3. Registered Nurse (RN) L did not prevent possible cross contamination between wounds for R3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure diabetic foot care and treatment was provided, in accordance with professional standards of practice for 6 residents (R3, R4, R22, R56, R80, R83) of 6 diabetic residents reviewed for diabetic foot care in a sample of 20 residents. The facility did not:-Have physician orders for daily diabetic foot checks on R3, R4, R22, R56, R80, R83.-Have documentation in medical records that diabetic foot assessments and/or cares for R3, R4, R22, R80, and R83-Perform diabetic nail cares, specifically trimming toenails for R3. The facility's failure to provide diabetic foot care to residents could result in physical, mental and psychological harm to residents, including infection and poor hygiene.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the residents' comprehensive plan of care for 2 of 20 residents (R7 and R1) reviewed. R7 has chronic lymphedema. R7's lymphedema was not being routinely assessed through measurements to monitor for worsening. R7 had a 2,000 ml daily fluid restriction that was not monitored daily. Facility did not document fluid intake every shift for R1 who is on fluid restrictions as ordered by physician which could result in fluid overload for R1. Facility did not perform and document daily weights and pulses as ordered by physician for R1 which could result in physical harm for R1. Facility did not notify physician for weights outside of parameters as ordered by physician for R1 which could result in physical harm for R1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure falls were investigated thoroughly to determine root cause, implement new safety interventions, and ensure adequate supervision for 1 of 8 residents (R) reviewed (R72). On 11/22/25, R72 had an unwitnessed fall. Root cause determined to be care planned intervention not in place. Facility did not complete thorough investigation to determine cause of safety intervention not in place, complete staff interviews, or evaluate staff competency. On 12/23/25, R72 had an unwitnessed fall with a resulting injury. Root cause determined to be care planned intervention not in place. Facility's investigation did not determine cause of safety intervention not in place, complete interviews with staff, or evaluate staff competency. On 03/28/26, R72 had an unwitnessed fall using equipment assessed to be unsafe without supervision. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received care and services for administration of parenteral medications consistent with professional standards of nursing practice for 2 residents (R17, R96) of 2 residents receiving parenteral medications reviewed in a sample of 20 residents. ~ R17 did not have arm circumference measurements at insertion site documented to ensure the peripherally inserted central line (PICC) was patent and not infiltrating into surrounding tissue during intravenous medication administrations. ~RN did not measure the circumference of R96's arm to ensure IV fluids via PICC line were not infiltrating surrounding tissue and not into the blood stream. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services, including acquiring, receiving, and dispensing medications to meet the needs of 1 of 2 residents reviewed (R12). R12 had a physician order on 8/19/25 for Fidaxomicin for Clostridium Difficile (C-Diff). Pharmacy stated the medication was not available. Physician changed the order to Vancomycin HCL Capsule 125 mg by mouth every 6 hours until Fidaxomicin became available. Vancomycin was to be delivered on 8/20/25, and on 8/21/25, the pharmacy still had not delivered the Vancomycin. R12 was hospitalized on [DATE] to receive the Vancomycin for C-Diff management. The facility's Pharmacy Services manual read in part, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse by another resident for 1 of 3 residents reviewed (R1). R2 was found in R1's room sitting next to R1's bed in wheelchair with his hand under the blanket on R1's bed. Facility did not protect R1 from further potential abuse when Surveyor's observations confirmed 15-minute checks on R2 were not performed, and R2 entered R1's room four more times after the incident.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional practice. This occurred for 1 of 3 medication storage rooms/carts observed, resulting in the potential to affect all 44 residents that reside on the north wing out of 73 residents that reside in the facility. This is evidenced by: On 4/30/25 at 6:49 AM, during inspection of north storage med room, Surveyor noted expired medications in the resident stock medications that included: Two bottles of Molnupiravir 200 mg (antiviral medication) one bottle unopened expired 8/23/24 and another bottle of Molnupiravir 200 mg unopened exp. 10/8/24. Surveyor interviewed Assistant Director of Nursing (ADON) G, who stated those should not be on the shelf. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not notify provider as indicated for development of a skin wound for 1 of 18 residents, (R) R43, reviewed. This is evidenced by: R43 was admitted to the facility on [DATE]. R43's current diagnoses include, congestive heart failure, cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection, dementia, and muscle weakness. Minimum Data Set (MDS) admission assessment dated [DATE] documented R43's Brief Interview for Mental Status (BIMS) score of 5/15 indicating severe cognitive impairment. R43 requires maximum assistance from staff for lower body dressing, transfers, and showers. R43 is at risk for pressure injuries. Initial care plan was developed for potential for skin breakdown related to dementia, limitations in mobility, occasional bowel incontinence, cardiac diagnosis, and pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize and assess an inability to perform Activities of Daily Living (ADL)s and implement interventions in accordance with the residents' assessed needs for 2 of 2 residents reviewed (R55, R65).

Inspectors wroteBased on observation, record review and interview, the facility did not report and respond to resident pain promptly to ensure prompt assessment and treatment of pain for 1 of 3 residents reviewed for pain. R25 expressed pain and need for medication during care. Certified Nursing Assistant (CNA) F did not stop care and summon a nurse for assessment and treatment of R25's pain. Nursing assessment of R25's pain was not initiated until 4 hours after R25's expressed pain. This is evidenced by: Surveyor requested and received the facility policy titled Pain Management dated 10/24/23. The policy in part read: Purpose: Nursing homes residents are at high risk for having pain that may affect function, impaired mobility, impaired mood, disturb sleep and diminish quality of life. Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and 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 for 4 of 4 residents reviewed. (R43, R53, R27, R76) R43 is on contact precautions and staff did not wear the proper personal protective equipment (PPE) when providing cares. Hand hygiene was not performed for R53 as required for catheter cares, or during medication pass for R27 and R76. This is evidenced by: Example 1 R43 was admitted to the facility on [DATE]. R43's current diagnoses include, congestive heart failure, cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection (MRSA), dementia, and muscle weakness. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the daily nurse staffing information was posted at the beginning of each shift. This has the potential to affect all 73 residents in the building. The facility did not update the daily nursing staff postings when there were schedule changes. Evidenced by: The facility policy titled: Sufficient Nursing Home Services: dated 09/01/2000, states: 4.1 Nurse Staffing information. NCHC must post the following information on a daily basis: -Facility name -The current date -The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. According to federal regulations, the facility must post the nurse staffing data on a daily basis at the beginning of each shift. Data must be posted as follows: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents (R) receive food that accommodates the residents' preferences and options of similar nutritional value are provided for residents who choose not to eat the food that is initially served for 1 of 3 residents reviewed. (R6)

Inspectors wroteBased on interview and record review, the facility did not develop a resident-to-resident altercation comprehensive person-centered care plan for 3 of 3 sampled residents (R2, R1 and R3).

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure 2 of 4 residents (R1 and R24) reviewed were administered medications in a safe manner. This is evidenced by: Surveyor reviewed R1's medical record and noted the following: R1 was admitted on [DATE] with diagnoses of dementia with psychotic disturbance and dysphagia. R1 has an activated power of attorney (APOA) with incapacitation documentation dated 01/12/24. The admission minimum data set (MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 15, indicated she is cognitively intact. On 03/04/24 at 10:06 AM, Surveyor observed R1 in private room ambulating self with walker to sit on her bed. Surveyor asked permission to enter room and interview R1. Surveyor observed a medication administration cup with 4 various pills on R1's bedside table. Surveyor asked R1 if those were R1's pills. [...]

Inspectors wroteBased on interviews and record reviews, the facility did not ensure their designated Infection Control Preventionist (ICP) completed training in infection control (IC) prior to assuming the role, without oversight by another IC trained individual. This has the potential to affect all 83 residents in the facility. This is evidenced by: An ICP is an essential component of an effective infection control program and is the person designated by the facility to be responsible for infection control. The Centers for Disease Control and Prevention (CDC), CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings updated October 2022, states in part, . Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . [...]