Pine Crest Health & Rehabilitation

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services for 1 of 3 residents (Resident #32) reviewed for beneficiary notification.

Inspectors wroteBased on record review and staff interviews, the facility failed to revise a resident's care plan with current cardiopulmonary resuscitation code status for 1 of 21 residents (Resident #64) reviewed for care plans.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities resulting in a medication error rate of 8% for 1 of 5 residents observed during medication administration observation (Resident #6).

Inspectors wroteBased on observations, record review, interviews with Registered Dietitian, Speech Therapist, and staff, the facility failed to modify a resident's diet order to meet her individual needs for 1 of 5 residents reviewed for nutrition (Resident #47).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when Nurse #2 did not doff her gloves, perform hand hygiene and don clean gloves prior to cleaning wound and applying new wound dressing to Resident #31's sacrum. Additionally, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse #1 did not don a gown during a high contact care activity which included dressing Resident #31 who had a chronic wound and feeding tube. The deficient practice occurred for 2 of 5 staff members observed for infection control practices (Nurse #1 and Nurse #2).

Inspectors wroteBased on record reviews, staff, responsible person (RP) and Medical Director (MD) interviews, the facility failed to notify the MD when multiple doses of significant morning medications (seizure medication, insulin, depression medication, and chronic kidney and heart failure medication) were not administered due to Resident #20 being out of facility for dialysis treatment and not administered her morning medications. There was a high likelihood of failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. [...]

Inspectors wroteBased on observations, record reviews, and staff interviews the facility failed to maintain an environment free of accident hazards for 1 of 5 residents (Resident #66) reviewed for supervision to prevent accidents. On 2/21/24, Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with a handle. Resident #66 was unattended in the hallway outside of the maintenance room, the door was unlocked and partially open. NA #6 asked Resident #66 to hand her the long ridged knife with handle which she did with no issues, placed the knife back inside the maintenance room and shut the door without locking the door. The maintenance room was observed on 4/17/24 to be unlocked. [...]

Inspectors wroteBased on record review, resident, staff, and Medical Doctor (MD) interview the facility failed to prevent a significant medication error by failing to administer morning medications for a dialysis resident (Resident #20) for 1 of 3 residents reviewed for assuring the facility was free of medication errors. Resident #20 attended dialysis treatments on Tuesday, Thursday, and Saturday from 5:30 AM to 10:30 AM and was not administered her significant morning medications. Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. Immediate jeopardy began on 04/02/24 when the facility failed to administer Resident #20's morning medications. [...]

Inspectors wroteBased on record review, observations, and staff, resident, Registered Dietitian, and Food Service Provider Representative interviews the facility failed to ensure that fried chicken was completely cooked before serving to residents on lunch trays by 1 of 2 cooks (Cook #1). Undercooked fried chicken was served to 15 of 69 residents and 5 of 15 residents consumed the undercooked fried chicken. Resident #54, Resident #21, Resident #37, Resident #51, and Resident #45 were noted as having consumed the undercooked fried chicken. This unsafe food handling practice had a high likelihood for food borne illness for residents. In addition, the facility failed to have food items labeled with a use by or expiration date and discard food items by the use by date in the dry storage room. [...]

Inspectors wroteBased on observations, record review, picture, manufacturer's instructions, resident, family member #5, staff, consultant pharmacist, and Medical Director interviews the facility failed to ensure that single resident insulin pens were not shared between residents. On 07/10/23 Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Regurgitation (emission) of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one resident, even when the needle is changed. This has the high likelihood to spread bloodborne pathogens such as human immunodeficiency virus (HIV), Hepatitis B and Hepatitis C. This affected 1 of 3 residents reviewed for infection control. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to refer two new residents with serious mental health diagnoses, and one resident with a new mental health diagnosis for Preadmission Screening and Resident Review (PASRR) level II for 3 of 3 residents reviewed for PASRR (Resident #4, #19, and #54).

Inspectors wroteBased on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 5 of 5 residents reviewed for activities (Residents #203, #102, #114 #216 and #46). The residents expressed not being able to leave the facility made them feel frustrated, awful, forgotten about, hemmed in, angry, and mad. The residents further stated they hated being stuck in the building all the time and once you get here, they won't let you leave.

Inspectors wroteBased on record review, resident and staff interviews the facility failed to provide breakfast, a bagged meal or snack for 2 of 2 residents (Resident #20 and #21) reviewed for dialysis.

Inspectors wroteBased on observations, record review and staff interview the facility failed to verify [NAME] #1's competencies and certifications for food production and meal service prior to first day of employment.

Inspectors wroteBased on observations, resident and staff interviews the facility failed to provide evening snacks to residents when requested for 4 of 4 residents (Resident #9, #20, #21, and #171) reviewed for frequency of snacks. This practice had the potential to affect other residents who requested evening snacks.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation survey that occurred on 12/16/21, the recertification and complaint investigation survey that occurred on 12/30/22 and the complaint investigation survey that occurred on 02/23/23. This failure was for one deficiency that was originally cited in the area of Free of Accidents Hazards/Supervision (F689). The recertification and complaint investigation survey that occurred on 12/16/21 and the recertification and complaint investigation survey that occurred on 12/30/22. [...]

Inspectors wroteBased on record review, resident, family, and staff interview the facility failed to protect Resident #172's private health information when her insulin pen was left at the bedside of another resident for 1 of 2 residents reviewed for privacy and confidentiality.

Inspectors wroteBased on record review, and resident and staff interviews the facility failed to protect a resident's right to be free from inappropriate physical contact by a staff member. On 4/1/24 Nurse Aide (NA) #1 was observed lying in bed with Resident #46. This deficient practice occurred for 1 of 5 residents reviewed for abuse, neglect, and exploitation.

Inspectors wroteBased on record review, resident interviews and staff interviews the facility failed to follow their policy in the areas of reporting and protection. The facility failed to immediately report inappropriate staff to resident physical contact when Nurse Aide (NA) #1 was observed by another staff member (NA #3) lying in bed with Resident #46. NA #1 continued to work shifts on 4/1/24, 4/5/24, 4/6/24, 4/7/24. One of 5 residents were reviewed for abuse.

Inspectors wroteBased on observations, record review, resident, and staff interviews the facility failed to stop wound care when Resident #1 complained of pain of a 7 on a scale of 1-10 and address her pain before finishing the wound care for 1 of 1 residents reviewed for pain.

Inspectors wroteBased on observation, record review, resident, and staff interviews the facility failed to provide care in a manner that maintained the resident's dignity by not providing incontinence care when needed. This is evidenced by Resident #266 feeling violated. This occurred for 1 of 4 residents reviewed for dignity. (Resident #266)

Inspectors wroteBased on observation, record review, resident, and staff interviews, the facility failed to provide incontinence care, which resulted in resident #266 feeling violated for 1 of 6 dependent residents reviewed for activities of daily living (ADL). (Resident #266)

Inspectors wroteBased on observations and staff interview, the facility failed to label, date and seal open food items stored for use in 1 of 1 walk- in refrigerator and 1 of 1 reach in cooler. This practice had the potential to affect the food served to residents.

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey conducted on 12/16/21. This was for 6 deficiencies that were cited in the areas of Resident Rights/Exercise of Rights (F550), Reasonable Accommodations of Needs/Preferences (F558), Care Plan Timing and Revision (F657), ADL (Activities of Daily Living) Care Provided for Dependent Residents (F677), Free of Accident Hazards/Supervision/Devices (F689) and Food Procurement, Storage/Preparation/Serve under Sanitary Conditions (F812) on 12/16/21 and recited on the current recertification and complaint survey of 12/15/22. [...]

Inspectors wroteBased on record reviews, and interviews with family member, and staff, the facility failed to provide foot pedal on a wheelchair for a resident transported by the facility to a specialist appointment for one of one resident reviewed for accommodation of needs (Resident #114).

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to maintain a home like environment and wall integrity in residents' rooms for 2 of 9 sampled residents (rooms [ROOM NUMBERS]) on 1 of 3 hallways.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to invite a resident and/or her representative to participate and provide input in care planning for 1 of 3 sampled residents (Resident #18) and failed to update the care plan to reflect the current advance directive for 1 of 3 residents reviewed (Resident #13).

Inspectors wroteBased on observation, record review, resident, staff, and Care Coordinator for Podiatry interviews, the facility failed to ensure toenails were trimmed and to refer residents to podiatry services for 2 of 2 diabetic residents reviewed for foot care. (Resident #30 and Resident #50)