Pinecrest Center for Rehabilitation and Healing

Inspectors wroteBased on observations, interviews and record review facility failed to ensure proper storage of medication and biologicals for five residents (Residents #381, #62, #47, #12 and #65) as evidenced by observations of bottled pills inside a plastic bag at Resident 381's bedside, a bottle labeled Zicam (cold remedy) at the Resident # 62's bedside, a tube labeled Zinc Oxide Ointment at the Resident#12's bedside two bottles labeled Acetic Acid Irrigation Solution at Resident # 47's bedside and a bingo card of discontinued medication for Resident#65. There were 83 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure residents' personal information was kept private as evidenced by observations of paperwork containing residents' information left visible and unattended in a public area.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure their medication error rate were 5% or lower as evidenced by an error rate of 13.89 % out of 36 opportunities. There were 83 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interview and record reviews the facility failed to ensure a routine breathing medication was reordered and received in a timely manner for one resident (Resident #48) with a diagnosis of Seizure and Asthma, out of three sampled residents as evidenced by an Inhalation medication for Asthma unavailable at prescribed time.

Inspectors wroteBased on record review and interview, the facility failed to implement policies and procedures for ensuring the timely reporting of abuse and an injury of unknown origin resulting in serious bodily harm for 2 out of 23 sampled residents (Resident #140 and Resident #389)

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one of of 23 sampled residents (Resident #87) that was discharged home and coded as discharged to the hospital. This deficiency has the potential to affect 79 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan related to skilled services for one out of 23 sampled residents. (Resident #289)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they were free of a significant medication error for one out of 23 sampled residents as evidenced by during the medication administration observation Registered Nurse (Staff A) drew insulin from the insulin pen with an insulin syringe for administration to resident #16 and demonstrated the incorrect procedure for administering insulin to resident #16.

Inspectors wroteBased on record review and interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F656, Develop and Implementation of Comprehensive Residents Centered Care Plans related to the development of the resident's Activities of Daily Living care plan for one out of 23 sampled residents (Resident # 289).

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to provide a clean and sanitary environment for two residents (Resident #535 and Resident #586) out of two residents whose rooms were observed; as evidenced by discarded items on the floor( disposable mask, enteral tubing caps,medical gloves on floor, plastic and paper items) visible stains on resident's gown, soiled sheets, overflowing garbage bin. This deficient practice has a potential affect the health and well-being of all the residents residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a comprehensive assessment for one (Resident #585) out one resident whose Minimum Data Set (MDS) was reviewed, by not completing the required Resident Assessment Instrument (RAI) within the required 14-days regulatory time frame.

Inspectors wroteBased on record review and interview the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for Resident # 485. This deficiency had the potential to affect 85 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow and implement nursing care plan intervention for one (Resident #535) out one resident whose care plans were reviewed. As evidence by The facility's staff failed to offload the heels as ordered for Resident #535.

Inspectors wroteBased on observation, record review and interview, the facility failed ensure appropriate treatment and services to increase range of motion and or to prevent further decrease in range of motion was provided as ordered for one (Resident #27) out of one resident reviewed. This practice has the potential to increase the risk of negative resident outcome for residents residing in the facility require services related to range of motion.

Inspectors wroteBased on observation, record review and interview the facility failed to provide adequate supervision to ensure the safety of a vulnerable resident (Resident #185) who was newly admitted to the facility, as evidenced by Resident #185 left the facility through an exit door undetected, approximately four (4) minutes after being admitted to the facility. There were 86 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure enteral feeding was administered as ordered for 1 resident (Resident # 535) out of 1 resident reviewed for tube feedings out of the 10 residents residing in the facility receiving nutrition and hydration via tube feeding at the time of this survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide appropriate storage of medications/Pharmaceuticals and medical supplies. As evidenced by expired medical supplies in one (South Station medication storage room) out of two of the facility's medication storage rooms and unidentified pills found in medication carts. This had the potential to affect 86 residents residing in the at the time of this survey.

Inspectors wroteBased on record review and interview, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F689 Free of Accident Hazards/Supervision/Devices. There were 86 residents residing in the facility at the time of this survey. Review of the facility's survey history revealed the facility was cited F689 Free of Accident Hazards/Supervision/Devices during the survey with exit date of 03/05/2020 related to a resident having a cigarette lighter in their possession. During this survey with exit date of 11/03/2022 the facility was cited F689 again related to the elopement of a newly admitted resident. The facility's Quality Assurance and Performance Improvement (QAPI) Plan provided by the facility revealed: [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement infection prevention and control precautions for a resident on contact precaution Resident #59 and Resident #78 whose room was next to Resident #59 and they shared a bathroom while Resident #59 was on Contact Precautions. This affected 2 of 21 sampled residents.