Pinecrest Medical Care Facility

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and resident representative comprehensive information of resident appeal rights prior to transfer out of the facility for three Residents (R5, R72, and R73) of three residents reviewed for transfer and/or discharge.

Inspectors wroteBased on interview and record review, the facility failed to follow the Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) determination for three Residents (#3, #48, and #57) out of three residents reviewed for PASARR, resulting in the potential for delayed mental health services and unmet psychosocial needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a thorough trauma assessment to identify triggers and follow-up on identified concerns related to suicidal ideation for one Resident (12) of one resident reviewed for Trauma-Informed Care, resulting in the potential for the Resident to experience re-traumatization, feelings of low self-worth, worsening depression and fear.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program in accordance with facility policies to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Document signs and symptoms of infections. 2. Conduct departmental surveillance for adherence to infection control practices. 3. Handle meal trays for residents in transmission-based precautions in accordance with facility policy. 4. Provide barriers for insulin pens during medication administration. 5. Ensure urinary catheter drainage bag and tubing remained off the floor. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 63 residents in the facility.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to revise or update care plans to reflect residents' status for five Residents (R50, R39, R20, R32, and R29) of seventeen residents reviewed for care plans. This deficient practice resulted in the potential for inadequate care and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to meet the needs of the residents. This deficient practice resulted in an inability to provide needed services as voiced by 10 of 10 residents in attendance at a confidential group meeting and in an inability to sufficiently supervise 4 of 4 residents (R3, R17, R41, and R23) residing on the dementia unit.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1.) safely securing narcotic medications in one of two medication rooms; 2.) not dating biologicals in one of three medication carts reviewed for medication storage.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to honor the advanced directive for one Resident (R20) of four residents reviewed for advance directives. This deficient practice resulted in the potential for residents' decisions regarding end-of-life care and medical care to not be followed by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report potential abuse to the State Agency as required for two Resident (R23 and R45) of three Residents reviewed for abuse reporting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate potential abuse to the State Agency as required for two Resident (R#23 and R#45) of three Residents reviewed for abuse investigating.

Inspectors wroteBased on interview and record review, the facility failed to provide written transfer notification to the resident and resident's representative including reason, effective dates, and the location to which the resident was being transferred for one Resident (R39), of two residents reviewed for transfers out of the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for two Residents (R41 and R54) of 17 residents reviewed for care planning. This deficient practice resulted in the lack of care plan goals and interventions, with the potential for unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medication administration to meet professional standards 1.) administer antibiotics according to physician order and 2.) flush peripherally inserted central catheter (PICC) for one Resident #32 of four residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the nutritional needs and preferences for two Residents (R29 and R54) of 3 residents reviewed for nutrition. This deficient practice resulted in residents not receiving prescribed diet, food preferences, experiencing thirst, and potential risk for physical decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides completed required dementia training and demonstrated the skills and techniques necessary to care for residents for three contracted Certified Nurse Assistants (CNAs F, AA and BB) of three contract nursing staff reviewed for competency evaluation, resulting in the potential for unmet physical and psychosocial needs for all 63 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with three errors identified out of 30 opportunities, affecting two Residents (R30 and R32) of four residents observed for medication administration, resulting in a medication error rate of 10.00 percent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive dining equipment for two Residents (R22 & R29) of three residents reviewed for adaptive dining equipment needs. This deficient practice resulted in increased difficulty with food consumption and independent eating with the potential for decreased food/fluid intake and risk for weight loss.

Inspectors wroteBased on interview and record review the facility failed to maintain a complete infection control program, including an outbreak line listing and surveillance mapping during an RSV (contageous respiratory illness) outbreak in the facility that had the potential to affect all 65 vulnerable residents in the facility. This deficient practice resulted in the potential for sustained spread of RSV within the facility resident population.

Inspectors wroteThis deficiency pertains to Intakes: MI00132367 and MI135306. Based on observation, interview, and record review, the facility failed to provide treatment and services to promote healing of pressure ulcers, including one Stage 3 pressure injury which resulted in harm, for three Residents (R42, R17 and R68) of four residents reviewed for pressure ulcer care. This deficient practice resulted in delayed wound healing, worsening of condition, and increased risk of infection.

Inspectors wroteThis deficiency pertains to Intakes MI00134358, MI00132367, and MI00131319. Based on observation, interview, and record review, the facility failed to ensure sufficient staff to provide nursing related services, assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, based on resident acuity and diagnoses of the resident population. This deficient practice resulted in unmet resident care needs and inadequate supervision to prevent and respond to resident needs.

Inspectors wroteThis deficiency pertains to Intakes: MI00134358, MI00132367, MI00131319. Based on observation, interview, and record review, the facility failed to perform annual licensed nurse and nurse aide competency evaluations and ensure licensed nursing staff and certified nurse aides (CNAs) had the specific competencies, skill sets, and techniques necessary to care for two Residents (R4 and R42] of four residents reviewed for pressure ulcer and catheter care. This deficient practice resulted in improper catheter and wound care technique and the potential for worsening of condition for both residents and had the potential to affect all facility residents.

Inspectors wroteThis deficiency pertains to MI00134358, MI00132367, MI00131319. Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was designated and served as the Director of Nursing (DON) on a full-time basis. This deficient practice resulted in the inability to provide in-person supervision over the activities of the Nursing Department. This deficiency had the ability to affect all 68 facility residents.

Inspectors wroteThis deficiency pertains to Intakes MI000134358, MI00132367, and MI00131319. Based on interview and record review, the facility failed to complete performance reviews of all nurse aide at least once every 12 months. This deficient practice resulted in the potential for quality-of-care concerns related to lack of training to meet the Certified Nurse Aide (CNA's) performance-based education needs. This deficient practice has the potential to affect all 68 vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by failing to label, date, and store food to ensure it was kept free from contamination and failed to properly clean areas with a potential to contaminate food during preparation. This deficient practice had the potential to result in food borne illness among any or all 39 residents in the facility.

Inspectors wroteThis deficiency pertains to Intake MI00132367. Based on interview and record review, the facility failed to implement their abuse policy to screen potential employees for a history of abuse by completion of reference checks for four recent hires ( Staff BB, JJ, OO, and PP) out of five staff reviewed for reference checks. This deficient practice resulted in the potential for individuals with a history of abuse to be employeed by the facility which had the potential to affect all 68 facility residents.

Inspectors wroteResident #15 (R15) Injury of unknown origin facility reported incident dated 8/30/22: Review of R15's face sheet, dated 8/30/22, reveal R15 was a [AGE] year-old female resident admitted to the facility on [DATE] with medical diagnoses including anxiety, severe intellectual disability, schizophrenia, and diabetes mellitus. Review of handwritten notes from a communication notebook between facility staff, dated 8/28/22 and timed 11p [11:00 PM] author unknown, read in part, [R15] yelled out on and off all night long. Slapped herself a few times. Left foot is hanging weird - she can't put pressure on it. Review of handwritten notes from communication notebook between facility staff, dated 8/28/22 and timed 3-7 [3:00 PM - 7:00 PM] author LPN C, read in part, .tried to transfer self to bed and was sit (sic) on floor next to w/c [wheelchair]. [...]

Inspectors wroteThis deficient practice pertains to Intakes: MI00132367, MI00134358, MI00136498, MI00134726, MI136473 and MI00137019. Based on observation, interview, and record review, the facility failed to ensure thorough investigations were completed for allegations of abuse including injuries of unknown origin for four Residents (R9, R29, R15, and R50) out of 21 residents reviewed for abuse. This deficient practice resulted in the potential for continuation of abuse.

Inspectors wroteThis deficiency pertains to Intake MI00132367. Based on observation, interview, and record review, the facility failed to ensure facility staff were trained and knowledgeable of the location of Cardiopulmonary Resuscitation (CPR) equipment for basic life support for residents with a full-code status. This deficient practice resulted in the potential for the delay or inability to perform CPR as a life-saving measure for facility residents.

Inspectors wroteResident #9 (R9) On 7/20/23 at 8:20 AM, an observation was made on the 600 hall of Certified Nurse Aide (CNA) VV assisting R9 in her wheelchair. CNA VV was pushing R9 down the 600 hall from room [ROOM NUMBER] down to the nursing station area (approximately 50 feet in distance). R9's feet were dragging on the floor below her as she sat in her wheelchair. CNA seen Surveyor witness R9 being pushed without foot pedals and immediately went to R9's room [room [ROOM NUMBER]] retrieved the foot pedals and placed them on R9's wheelchair. Review of R9's care plan, date printed 7/21/23, read in part, .I can't complete my cares on my own and need assistance of one to two staff to help me with my activities of daily living .I need my aides to .Whenever needed, use a regular wheelchair (one with a cushion, slip pads and foot pedals) . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from one medication cart out of four medication carts and one medication storage room out of three medication storage rooms reviewed for medication storage. This deficient practice resulted in the administration of expired insulin, the potential for decrease in potency of insulin, and medication errors.

Inspectors wroteThis deficiency pertains to Intakes MI00132367 and MI00134358. Based on observation, interview, and record review, the facility failed to provide respect and dignity during dining for three Residents (R9, R29, and R49) of 21 sample residents reviewed for dining. This deficient practice resulted in the potential for decreased meal consumption and dissatisfaction with dining assistance provided by facility staff.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychoactive medication for one Resident (#51) of five residents reviewed for psychoactive medications. This deficient practice resulted in Resident #51 (R51)and their Responsible Party not being informed of potential medication side effects/adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to facilitate resident self-determination related to dining location preference for one Resident (R3) of one resident reviewed for resident choices. This deficient practice resulted in frustration, anger, dissatisfaction with care, and feelings of helplessness when resident choices were not honored.

Inspectors wroteThis deficiency pertains to Intake MI00136498. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal abuse and neglect by Staff for one Resident (R9), out of eight residents reviewed for abuse. This deficient practice resulted in the potential for fear, humiliation, and feelings of helplessness when R9 was verbally disparaged following a fall from a chair.

Inspectors wroteBased on interview, and record review, the facility failed to completely assess and establish a baseline care plan within 48 hours that included measurable goals and interventions for one Resident (#58) of two sampled residents reviewed for development of baseline care plans. This deficient practice resulted in the facility's failure to address priority risk factors and individual needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective means of communication for one Resident (#50) of two residents reviewed for communication. This deficient practice resulted in Resident #50 struggling to communicate her basic needs, which resulted in feelings of frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate catheter care to prevent urinary tract infections for one Resident (R4) of one resident reviewed for catheter care. This deficient practice resulted in the potential for cross-contamination of feces and increased risk of urinary tract infection.

Inspectors wroteBased on interview and record review the facility failed to ensure the provision of trauma-informed care to mitigate triggers that may cause re-traumatization for one Resident (R3) of one resident reviewed for trauma-informed care. This deficient practice resulted in increased anxiety, flashbacks, and feelings of re-traumatization.

Inspectors wroteBased on interview, and record review, the facility failed to evaluate the use of antipsychotic medication for potential adverse consequences at least quarterly, if not more often for three Residents (#9, #36 and #51) of five sampled residents reviewed for unnecessary medications. This deficient practice resulted in the facility's failure to determine the potential for reducing or discontinuing psychoactive medications based on therapeutic goals and any adverse effects or functional impairment.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely radiology services in a timely manner and professional standards of practice after an unwitnessed fall for one Resident (R15) out of one resident reviewed for radiology services. This deficient practice resulted in the delay of medical treatment, diagnosis, and pain control for two fractures.