Pine Creek Care Center

In the surveyor’s words

From the most serious findings on record at Pine Creek Care Center, in the surveyor’s own words.

• Actual harm, isolatedF580Aug 31, 2022

  Based on interview, clinical record review, and facility policy review, the facility failed to notify or consult the Director of Nurses (DON) or a primary care provider for 1 of 4 sampled residents (Resident 1) of a change of condition when a resident's left foot was noted to have a purple discoloration. This failure led to a full day delay in the provision of physician services, a delay in treatment, and to the subsequent amputation of Resident 1's left lower leg. Findings: Review of Resident 1's clinical record revealed the following: A Resident Face Sheet, indicated Resident 1 was a [AGE] year old female admitted to the facility in July of 2022 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF656Aug 31, 2022

  Based on interview, clinical record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 4 sampled residents (Resident 1) based on admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure led to a delay in the provision of physician services, a one full day delay in treatment, and subsequent amputation of Resident 1's left lower leg. Findings: Review of Resident 1's clinical record revealed the following: A Resident Face Sheet, indicated Resident 1 was a [AGE] year old female admitted to the facility in July of 2022 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jun 19, 2026

  Based on observation, interview and record review, the facility failed to ensure food safety was maintained, when:1. An opened package of mozzarella cheese had blue and fuzzy spots; and2. One dietary staff had facial hair and did not fully cover with facial hair restraint. These failures had the potential to cause food-borne illness which could cause illness in 93 out of 93 medically vulnerable residents who consumed food from the facility kitchen. The census was 93.Findings:1. A concurrent observation in the walk-in refrigerator and interview with the Registered Dietitian (RD) and the Dietary Supervisor (DS) was conducted on 6/16/26 at 8:07 a.m. It was noted that an opened package of shredded cheese had blue and fuzzy spots. […]

• No harm, potential for more than minimal, widespreadF812Apr 19, 2024

  Based on observation, interview, and record review, the facility failed to meet food storage and service practices that met professional standards for food service safety when: 1. There were opened food packages found with no opened date label; 2. There were foods found removed from their original packaging without labels; 3. There was food stored in unsealed packaging; and, 4. The sanitizer solution was below the effective range. These failures decreased the facility's potential to prevent food borne illness for 89 residents who ate facility prepared foods. Findings: 1. During a concurrent observation and interview on 4/16/24 at 8:20 a.m. […]

• No harm, potential for more than minimal, patternF755Jun 19, 2026

  Based on observation, interview and record review, the facility failed to ensure controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR, an accountability record) for two of four randomly selected residents (Residents 44 and Resident 51). This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of controlled medications.Findings: A review of Resident 44's medical record indicated a physician's order for tramadol (a narcotic medication to treat pain) 50 milligrams (mg, a unit of measurement), give 50 mg by mouth every 6 hours as needed for moderate to severe pain (4-10)… […]