Allure of Pinecrest

In the surveyor’s words

From the most serious findings on record at Allure of Pinecrest, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jun 10, 2021

  Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) for the use of Personal Protective Equipment, (PPE) for resident (R144) in transmission based isolation. This failure has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on June 8, 2021 when V3 (Housekeeper) went in and out of R144's isolation room without doffing PPE prior to leaving the room. V3 entered and exited R144's isolation room a total of three times wearing the same PPE. […]

• Immediate jeopardy, isolatedF684May 13, 2024

  Based on interview and record review the facility failed to assess and monitor a resident that experienced a change in condition and failed to implement interventions as ordered by the physician resulting in the death of one of 18 residents (R93) reviewed for quality of care in the sample of 18. The Immediate Jeopardy began on [DATE] at 11:00 AM when V9 CNA (Certified Nursing Assistant) reported a change in condition to V10 LPN (Licensed Practical Nurse) and V10 instructed V9 to wait until R93's lunch tray arrives. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 11:08 AM. […]

• Actual harm, isolatedF659Apr 13, 2026

  Based on interview, and record review the facility failed to provide documentation showing staff was qualified to replace a gastrostomy tube (g-tube) per standards of practice for 1 of 4 residents (R1) reviewed for staff qualifications in the sample of 4. This failure resulted in R1's g-tube migrating into the small intestines leading to complications requiring hospitalization.Findings Include: On 4/13/26 at 12:10 PM, V1 (Administrator) said she did not know if V2 had any certification or training on changing a urinary catheter g-tube and to ask V2 directly. On 4/13/26 at 12:16 PM, V2 (Director of Nursing/DON) said she was not sure what prompted R1's urinary catheter g-tube to be changed, the nurse approached her and said the family wanted her to change it. […]

• Actual harm, isolatedF693Apr 13, 2026

  Based on observation, interview, and record review the facility failed to monitor a urinary catheter gastrostomy tube (g-tube) placement, failed to have policies in place for the care of a urinary catheter g-tube, and failed to have polices in place for replacing a urinary catheter g-tube for 1 of 2 residents (R1) reviewed for gastrostomy tubes in the sample of 4. This failure resulted in R1's being hospitalized due to her gastrostomy tube advancing into her small intestine causing a partial small bowel obstruction and pancreatitis.Findings Include: On 4/9/26 at 10:09 AM, V13 (R1's son) said after R1's g-tube was replaced, the tube was leaking. The only part of the tube sticking out of R1 was the nipple on the end. V9 and V2 were at the bedside looking at R1's g-tube. […]

• Actual harm, isolatedF684Sep 23, 2024

  Based on interview and record review the facility failed to obtain the necessary weights on residents (R1, R5) with diagnosis of congestive heart failure (CHF). The facility failed to obtain and complete the necessary lab work on resident (R1) with diagnoses of CHF and chronic kidney disease. These failures contributed to R1 being re-hospitalized with diagnoses of fluid overload and an exacerbation of CHF. These failures apply to 2 of 5 residents (R1, R5) reviewed for necessary care and services in the sample of 5. The findings include: 1. R1's hospital discharge instructions dated 12/20/23 showed R1 was hospitalized , from 12/10/23-12/20/23, due to bacterial endocarditis (infection around the heart) and respiratory failure. […]