Pine Creek Manor Skilled Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Pine Creek Manor Skilled Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 11, 2022

  Based on observation, interview and record review the facility failed to ensure the safety of a cognitively impaired resident (R607) when she walked out of the facility without authorization or supervision at 8:30 PM during a winter advisory without a coat or boots on resulting in Immediate Jeopardy when R607's condition and location were unknown until Emergency Medical Services (EMS) returned R607 to the facility at approximately 11:30 PM that evening. This deficient practice placed R607 and 3 other residents who were assessed to be cognitively impaired and 'at risk for elopement' (an unauthorized departure from the facility) at risk for serious harm, injury and or death from hazards outside the facility. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/28/2026 at 8:50 AM an interview with Dietary Manager (DM) E regarding date marking found a receive date and open date should be marked on food items.On 04/28/2026 at 8:52 AM observed cut carrots wrapped in plastic with a facility marked date of 4/15 in the two-door refrigerator located in the dry storage room. Further observation found chopped carrots wrapped in plastic with a number four written on the outside. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2026

  Based on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 04/28/2026 at 10:20 AM observed a hand sink with an inoperable hot water faucet in the laundry washing room. An interview with Laundry Aid (LA) H at this time found staff do not use the sink, and it has no warm water. On 04/28/2026 at 10:24 AM observed a utility sink located next to the hand sink in the laundry washing room with linens piled inside the basin. […]

• No harm, potential for more than minimal, widespreadF921Apr 30, 2026

  Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 04/28/2026 at 9:44 AM observed a mop sink in the soiled linen room with the hot water faucet missing. When the cold water faucet was turned on, water was observed leaking from the vacuum breaker.On 04/28/2026 at 9:49 AM observed the two-compartment utility sink in the soiled linen room with a chemical pre-dispensing system in place and the faucet left on. […]

• No harm, potential for more than minimal, widespreadF812Mar 13, 2025

  Based on observation, interview, and record review, the facility failed to: 1. Ensure pans were cleaned before stacking; 2. Properly date-label and store food in the kitchen; and 3. properly store ladles. These deficient practices had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: On 3/10/25 at 8:45 AM an initial tour of the kitchen was performed with Dietary Manager (DM) F, the following was observed: 1. Five sheet trays were heavily soiled and stored with clean pans in the clean pot/pan storage area. DM F agreed the sheet trays were heavily soiled and said they should not be used and stated, We need new ones. 2. […]