Pinecrest Retirement Community

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 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 3 of 5 residents (Residents #26, Resident #4, and Resident #8) and 4 of 7 staff (CNA H, LVN C and CNA F, and CNA G) reviewed for infection control. The facility failed to ensure CNA H followed infection control measures during dining service on 7/06/2026. The facility failed to ensure CNA H properly handled soiled linens and clothing for Resident # 26 on 7/06/2026. The facility failed to ensure CNA H properly cleaned Resident #26's soiled wheelchair cushion on 7/06/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms (The Arbors) reviewed for pharmacy services. The facility failed to remove expired influenza vaccines from the refrigerator in the medication room in The Arbors on 7/7/2026. These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 4 (Residents #42) residents reviewed for thickened liquid diets. The facility failed to ensure Resident #42 was not served thin liquids on 7/06/2026. This failure could place residents who received thickened liquid diets at risk of difficulty swallowing, possibly resulting in choking. Findings Included:Record review of Resident #42's facility face sheet, dated 07/06/2026, indicated Resident #42 was a [AGE] year-old male, admitted [DATE], with diagnosis of Dysphasia (difficulty with swallowing). Record review of Resident #42's admission MDS assessment, dated 06/08/2026, revealed a BIMS score of 14 that indicated Resident #42 had intact cognition. He required assistance with his ADLs. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 2 of 5 staff (CNA A and CNA B) reviewed for competent nursing care. The facility failed to ensure CNA A and CNA B were able to demonstrate competency in the skill of hand hygiene when they failed to perform hand hygiene and change their gloves during incontinent care provided to Resident #8 on 2/18/2026. These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.

Inspectors wroteBased on observations, interviews, and record review the facility failed to 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 1 of 8 residents (Resident #8) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed contact precautions, changed their gloves, and did not touch clean items with dirty gloves when incontinent care was provided to Resident #8 on 2/18/2026. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (HC Arbor, HC Woodlands, Rehab). The dietary staff did not accurately test and log the dish machine for hot water sanitizing on 06/01/25 and the morning of 06/02/25. DA B served food without taking the holding temperatures on the rehab unit. Cook C did not take holding temperatures in the main kitchen on the foil covered plates and on any of the alternate food items. DA D served food whose temperatures were below appropriate holding temperatures on HC Arbor. She did not take temperatures on all 4 foil covered plates with food items. DA D used gloved hands to serve rolls, French fries, chicken strips, and onion rings after handling other items in the satellite kitchen on HC Arbor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's main kitchen observed for kitchen sanitation. The soda drink dispenser had undated (date when opened) and expired soda syrup concentrates connected and available to be served. The freezer had open to air, improperly labeled and expired foods. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 28 dietary staff (Dietary Staff D, E and F) reviewed for reviewed for food and nutrition services. The facility did not ensure Dietary Staff D, E and F had a current food handlers' certificate while working in the facility's kitchen on 04/29/24 to 05/01/2024. This failure could place all residents who consumed food prepared from the kitchen at risk of food-borne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents (Residents #6) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #6 as having restraints on her MDS assessment. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 12 residents (Resident #196) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission on Resident #196 and provide a care plan summary to the resident or representative. This failure could place residents at risk of not receiving correct and/or necessary care/treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #37) On 4/04/2024 CNA G failed to ensure a safe transfer by leaving Resident #37 standing in the sit to stand lift unattended and left the room to retrieve supplies and Resident #37 fell. This failure could place residents who required supervision at risk of injury or accidents and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 2 resident personal refrigerators reviewed for food safety (Resident #9). The facility failed to ensure the refrigerator for Resident #9 did not contain expired cheese sticks, prune juice, or nutritional shakes. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to 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 1 of 10 residents (Resident #6) and 1 of 8 staff (CNA A) reviewed for infection control. CNA A did not sanitize/wash hands between glove changes when providing incontinent care on 4/29/2024. This failure could place residents at risk for exposure to and transmission of diseases and infections.