Pine Crest Health Care

Inspectors wroteBased on interview, observation, and record review the facility failed to follow their Activities of Daily Living Policy to provide podiatry care to R7, this failure affected one (R7) of three residents reviewed for ADL Care (grooming). On 4/30/2026 at 2:13 P.M., R7 gave permission for V13 (CNA) to assess R7s toenails with the state surveyor. V13 described R7 left and right big toenails as long and thick, and looked like R7s toenails had not been cut for like a year. V13 stated she previously told R7s floor nurse to refer R7 to the podiatrist. On 4/30/2026 at 2:26 P.M., V11 (Licensed Practical Nurse/ LPN) and V14 (R7s family member) also observed R7s left and right toenails and stated R7s toenails were thick and long. Nurse surveyor observed V11 putting R7s right sock on and R7 flinched his foot. V14 stated R7s right toe is sensitive. [...]

Inspectors wroteBased on record review, interview and observations the facility failed to provide a safe, functional, sanitary and comfortable environment for the residents of the facility. This failure involved the common area shower rooms on both the first and second floors and affects all residents in the facility. The shower facilities available to the residents are in need of repairs and deep cleaning to give the residents a space to feel comfortable using on a daily basis. R1 will be known as R5 and is not available to be interviewed while writer was at the facility. R5 is a 67 year of female whose diagnosis includes: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its abuse policy by not ensuring that residents were free from physical and verbal abuse. This affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R1 experiencing, a facility staff member directed inappropriate and profane language toward R1. R1 reported feeling disrespected, childlike, and angry as a result of the interaction. This also resulted in (R2) experiencing a facility staff member struck R2 on the head. Using the reasonable person concept, this action would cause a R2 to feel fear and intimidation. Findings Include: R1's brief interview for mental status dated 8/26/25 documents a score of fifteen which indicates cognitively intact. Social service note dated 8/12/25 documents: [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor and provide effective supervision to ensure that a resident with a history of alcohol abuse was able to get access to alcohol while in the facility. This affected one resident (R143) reviewed for supervision and monitoring. This failure resulted in R143 being able to obtain alcohol on two separate occasions in the resulting hospitalizations. [NAME], [NAME] (143) OLADINI, BOSEDE (32338) - Hazards/SupervisionR1's records show the following:Face sheet shows that R143 was admitted to the facility on [DATE] with diagnoses which include but are Alcohol Abuse, Opioid Abuse, Bipolar Disorder, Schizoaffective Disorder, Hypertension, Acute Kidney Failure, And Acute Respiratory Failure. Progress notes dated 6/6/25 at 6:55pm written by V13(LPN/Licensed Practical Nurse) states: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required daily nurse staffing information was accurately completed and consistently posted. These failures have the potential to affect all 161 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition services in the facility's kitchen by failing to: remove ice from the ice machine, clean the visible dirt on the ice machine, clean the food mixer, and failing to clean the debris left on the floor of the kitchen by the grease trap backing up from under the kitchen floor. These failures have the potential to cause food borne illness in all 159 residents that receive food from the facility's kitchen. Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that refrigerated milk cartons are stored at a temperature to protect against food spoilage(below 41 degrees), failed to clean the air vent/vent return above the food prep table, failed to clean the ice machine, failed to clean the food mixer, and failed to clean the debris left on the floor of the kitchen by the grease trap backing up from under the kitchen floor. These failures have the potential to cause food borne illness in all 159 residents that receive food from the facility's kitchen. Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that essential kitchen equipment such as the 3 Compartment sink water-drain works correctly to drain water without causing a drain back-up of grease/dirty water to the floor, failed to ensure that the milk refrigerator works efficiently to keep milk below 41 degrees Fahrenheit, and failed to fix the broken cover of the ice machine. These failures have the potential to affect all 159 residents that receive food from the facility's kitchen. Facility OLADINI, BOSEDE (32338) - KitchenOn 8/11/25 after the entrance conference, V1(Administrator) presented the facility census as 161, minus 2 residents who eat nothing by mouth (NPO), giving a total of 159 residents who receive oral foods from the facility's kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to clean and maintain the dryer lint screens thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 161 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failing to provide care in a manner that promotes the resident's right to dignity as evidenced by failing to cover urinary catheter drainage bags, failing to ensure residents had access to clothes when in public areas/view, failing to draw a privacy curtain when dressing a resident and failing to provide feeding assistance in a manner that promotes dignity. These failures affect 5 residents (R6, R7, R10, R24 and R129) in a sample of 70 residents reviewed for dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders and care plan for enteral feeding; failed to follow physician's order and resident's care plan to ensure that hip abduction pad is applied to a post hip replacement resident; failed to follow physician orders related to continuous oxygen use; failed to obtain physician orders/consultation for podiatric care and failed to provide podiatric care. These failures affect 4 residents (R6, R39, R75, R150) in a sample of 70 reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to refrigerate medications as instructed, failed to destroy discontinued narcotic medications, and failed to label medications with an appropriate open/expiration date in accordance with accepted professional standards. This failure affects 6 residents (R42, R51, R70, R107, R136, and R137) in a sample of 70 residents reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient personal protective equipment to meet the needs of residents that require enhanced barrier precautions. This failure has the potential to affect 4 residents (R5, R6, R24, R110) residents in a sample of 70 residents reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call lights in 2 out of 3 shower rooms on the second floor were functioning properly. This deficient practice has the potential to affect all 91 residents that reside on the second floor of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that handrails were secured along the resident corridors. This failure has the potential to affect 21 residents that reside within the 2400 unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 25 medication opportunities resulting in an 11% medication error rate. This failure affected two residents (R47 and R52) of five residents reviewed for medication administration.

Inspectors wroteBased on interview and record review the facility failed to have a system in place to prevent unauthorized and unsupervised leave from the facility. This failure resulted in one resident's (R1) elopement from the facility without staff knowledge who has documented assessments related to elopement/wandering behaviors. This was identified as an immediate jeopardy which begin on 07/17/25 at 8:55pm when R1 eloped from the facility without supervision and authorization. V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 07/28/25. On 08/04/25 acceptable removal plan was received after revision of the original plan submitted on 7/28/25. The Immediate Jeopardy was removed on 08/04/25, however, the non-compliance remains at the level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. [...]

Inspectors wroteBased on interview and record review the facility failed to revise a comprehensive care plan, failed to develop care plan with measurable goals, objectives and individualized interventions to meet the need for increased supervision in preventive interventions for one resident (R1) reviewed for elopement in the sample.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement resident-centered interventions on a resident with behavior of agitation and limited mobility on upper extremities in preventing injury for one (R3) of four residents reviewed for accidents. This failure resulted in R3 experiencing pain, swelling, and bruising to left upper and mid arm which requires emergent transfer to the hospital and was found to have an oblique displaced fracture through the proximal diaphysis of the left humerus.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment by using space heaters in residents' rooms; failed to ensure that four shower rooms on the first floor of the facility were clean and in good repair; and failed to maintain adequate temperature in residents' rooms and the first-floor dining room. This failure affected five (R1, R2, R3, R4 and R5) of five residents reviewed for environment.

Inspectors wroteBased on interview and record review the facility failed to follow their policy for weighing residents and failed to follow physician orders to weigh resident weekly, which resulted in a 6% unplanned weight loss. This failure applied to one of one (R1) residents reviewed for weight loss.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure applied to two (R1, R2) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 being punched in the face, falling backwards, and being transferred to the hospital with a diagnosis of right frontal maxillary process fracture (upper jaw)

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedure for mechanical lift transfers by not ensuring two staff were present while attempting to transfer a resident using the mechanical lift. This failure applied to one (R1) of three residents reviewed for accidents/hazards.

Inspectors wroteBased on interviews and record reviews, the facility failed to prevent or determine how an injury of unknown origin occurred for 1 of 3 residents (R1) reviewed for resident injuries in a total sample of three. This failure resulted in R1 suffering an acute left femur fracture that was discovered at an outside ortho appointment. Findings Include: R1 is an [AGE] year old with the following diagnosis: fracture of the right femur, aftercare following joint replacement surgery, dementia, and vitamin D deficiency. R1 was unable to be interviewed due to no longer residing at the facility. A Nursing note dated 9/27/24 at 11:20 AM documents R1 left the facility and went to the hospital for an appointment with an escort. The Veteran Visit Summary dated 9/27/24 documents R1 was admitted to the hospital for a new hip fracture. An acute left hip fracture was noted on x-ray. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was held at a safe and proper temperature before serving. This failure effect 143 residents out of 146 residents in the facility observed for food temperatures.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure cleanliness of washing machines and to keep the clean linens covered. The facility also failed to conduct annual test to prevent the growth of Legionella and other opportunistic waterborne pathogen in the building water system. This deficiency could affect the entire 146 residents who are using linens that are being washed in the facility and water that being used in the facility.

Inspectors wroteBased on observation interview, record review the facility failed to follow their policy in ensuring that ceiling tiles in the residents are free from watermarks or spots, and that vents in the residents' room are free from dust build up. This deficiency affects all four rooms (Rooms 205, 211, 2316, and 2210) reviewed for clean, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse. This deficiency affects one (R19) of three residents in the sample of 29 reviewed for Abuse prevention program.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to resident who is dependent with Activity of Daily Livings (ADL). This deficiency affects one (R103) of three residents in the sample of 29 reviewed for providing ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify early signs of skin impairment and provide treatment in timely manner. The facility failed to develop care plan and implement interventions to prevention skin impairment to resident who is at high risk. The facility also failed to follow manufacturer recommendation when using low air loss mattress. This deficiency affects two (R88 and R103) of three residents in the sample of 29 reviewed for providing Quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall preventive measures and updates fall care plan after each fall occurrence. This deficiency affects all three residents (R13, R88 and R146) in the sample of 29 reviewed for Fall Prevention Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to collaborate and coordinate care by failure to ensure that resident's updated medical records are available and accessible to all interdisciplinary team (IDT) in the facility. This deficiency affects two (R88 and R113) of three residents in the sample of 29 reviewed for Hospice Services Program.

Inspectors wroteBased on interviews, observations and record review, the facility failed to provide adequate supervision to 1 (R4) of 3 (R1, R3 and R4) residents and the physical enviornment review for accidents, this failure resulted in R4 gaining access to the laundry room, that should have been locked, and once R4 gained entry to the laundry room, the facilty's lack of supervision allowed R4 to gain access to a laundry detergent that spilled on his right foot causing a chemical burn that required treament at the local hospital.

Inspectors wroteBased on interview and record review, the facility failed to follow their physician notification policy and did not notify the physician when a small, metal piece was found in a resident's skin/scalp. This affected one of three (R1) residents reviewed for physician notification of a change. Findings Include R1 is a [AGE] year old with the following diagnosis: developmental delay, pressure ulcer of the left heel, spastic hemiplegic cerebral palsy, and fusion of the cervical spine. A Nursing note dated 10 4/11/23 documents R1 was admitted to the facility. R1 had a wound to the left heel and bilateral anterior ankles. There was a surgical incision scar to the neck. There is no documentation on any of these days that a small metal piece was found in or on R1's skin or that the physician was notified. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not preventing an incident of physical resident to resident physical attack. This affected two of four residents (R2, R3) reviewed for physical abuse. This failure resulted in R3 hitting R2 for standing close to R3 during the smoking break. Findings Include: R2 is a [AGE] year old with the following diagnosis: peripheral vascular disease, type 2 diabetes, and chronic kidney disease. R3 is a [AGE] year old with the following diagnosis: schizoaffetive disorder and schizophrenia. On 2/20/24 at 2:03PM, R3 stated R3 hit R2 in the face when out on the smoking patio. R3 reported the reasoning for hitting R3 was because R2 was getting to close to R3. R3 again began yelling at this surveyor and refused to answer any further questions on the incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a history of physical and verbal aggression attended psychosocial group management. This affected one of three (R3) residents reviewed for behavior management and interventions. This failure resulted in R3 physically attacking R2 during a smoking break for standing to close. Findings Include: R2 is a [AGE] year old with the following diagnosis: peripheral vascular disease, type 2 diabetes, and chronic kidney disease. R2 R3 is a [AGE] year old with the following diagnosis: schizoaffetive disorder and schizophrenia. No observations were made asking R3 to attend the groups held by social services. On 2/20/24 at 2:03PM, R3 instantly began aggressive and started yelling at this surveyor with any questioning. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to identify an acute change in a resident's respiratory condition and implement immediate effective interventions to improve respiratory status. This affected one of three residents (R8) reviewed for change in condition and assessment. This failure resulted in (R8) calling EMS (emergency medical services) 911 for assistance with difficulty breathing out of three residents reviewed for change in condition in a sample of 10. R2's oxygen saturation level was 72% when the paramedics arrived.

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse prevention policy by not immediately reporting an allegation of abuse and failing to conduct a full body exam at the time of the allegation. This failure effects one resident (R1) who has stated she was hit by a Cerified Nursing Assistant while receiving care.

Inspectors wroteBased on interview and record review, the facility failed to follow individualized care plan interventions to prevent a fall. This failure affected one resident (R3) and resulted in R3 sustaining a head laceration which required treatment rendered in a hospital emergency room.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its abuse policy and prevent an resident to resident physical assault. This affected two of four (R1, R2) residents reviewed for physical assault. This failure resulted in R2 wandering into R1's room and assaulting R1 with an aluminum reaching device.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an effective plan to monitor a resident with a history of wandering. This affected one of three residents (R2) reviewed for supervision. This failures resulted in R2 wandering into R1's room unsupervised subsequently assaulting R1 with an aluminum reaching device.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a written policy and procedure for disinfection of washer and dryer used in the laundry room. The facility also failed to keep washing machines free of detergent residue and grime (accumulation of dirt). This deficiency could affect the entire 128 residents who are using linens that are being washed in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a sanitary and comfortable environment in the patio and gazebo areas. This failure has the potential to affect all 138 residents listed on the facility census. The facility also failed to ensure the washing machine is in a safe operating condition. This deficiency could affect 128 residents who are using the linens that are being washed in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a working call system for seven residents (R1, R18, R82, R84, R93, R112, and R129) of 17 residents reviewed for call system in the sample of 28.

Inspectors wroteBased on observation interview and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 3 residents (R85) reviewed for residents' rights in a sample of 28. Findings Include: On 8/8/2023 at 11:45am R85 was observed in her room with the window drapes hanging down on one side. R85 said I asked the housekeeping supervisor to hang them up correctly and she never returned it looks abandoned in my room. On 8/8/2023 at 12:30pm V4(Housekeeping Supervisor) observed with the surveyor the window drapes hanging down. On 8/8/2023 at 12:40pm V4 said the curtains should not be hanging I will put them up as soon as possible. On 8/9/2023 at 10:40am V2(Assistant-Administrator) said all residents window drapes should be hanging correctly. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Incident/Accident Reports policy. Facility failed to report fall incident with injury to the Illinois Department of Public Health IDPH). This deficient practice affect one (R3) resident of three resident reviewed for fall incident in a total resident sample of 28. Findings Include: Documented on 8/4/23 at 6:48AM, reads in part: R3 observed in his room lying on the floor bleeding from right eye brow. R3 assessed with no other injuries found. Due to unwitnessed fall and being on blood thinners, R3 sent to local hospital for further evaluation. Ambulance ETA (Estimated Time of Arrival) 45 minutes. Physician Progress note dated 8/4/23 at 9:44AM, reads in part: R3 returned from ER (Emergency Room) status post fall with right eye brow laceration. R3 with 2 steri strips over laceration to right eye brow. On 8/10/23 at 11: [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow their Fall Prevention Program Policy and supervise a high risk for fall resident. This deficient practice affect one resident (R137) of three residents reviewed for fall incident in a total sample of 28 residents. Findings Include: R137 had a fall incident on 7/18/23. Nursing Progress Note dated 7/18/23 at 15:58, reads in part: R137 trying to transfer from her wheelchair to another chair and landed on bottom in dining area. R137 assessed with non-visible injuries. R137 did not hit her head witnessed by staff. On 8/10/23 at 11:03AM, V6 (LPN) stated that she was the assigned nurse for R137 that time. Denied witnessing the fall of R137 on 7/18/23. Stated that another nurse (V5) witnessed the fall of R137 in the dining room. Also stated that R137 is High risk fall. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow the physician's order for a resident who receives oxygen therapy. This deficiency affects two (R99 and R133) of three residents in the sample of 28 reviewed for Respiratory care.

Inspectors wroteBased on observation, interview and record review the facility failed to have coordinated care by ensuring that the resident's hospice medical records are available and accessible to all interdisciplinary staff in the facility. This deficiency affects one (R99) of three residents in the sample of 28 reviewed for Hospice Care Services.