Pine Creek Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Pine Creek Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Oct 3, 2024

  Based on interview and record review it was determined, for 2 out of 28 sampled residents, that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility failed to promptly identify, monitor, and intervene for an acute change in condition after two residents sustained a fall. Additionally, one resident did not have neurological assessments completed status post fall, and the other resident did not have timely intervention after changes were identified on the neurological assessment. […]

• Immediate jeopardy, isolatedF689Oct 3, 2024

  Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility failed to ensure that the resident had adequate supervision and assistance devices to prevent accidents. Specifically, a resident was not secured inside the facility vehicle during transport and fell out of her wheelchair. The fall resulted in the resident sustaining a Thoracic (T)11-T12 fracture and a contusion of the abdominal wall. Based on the facility's investigation and corresponding corrective measures, this was cited at past non-compliance with a correction date of 8/1/23. […]

• Actual harm, isolatedF689Aug 27, 2026

  Based on observation, interview, and record review, the facility did not ensure the residents' environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 23 sampled residents, a resident sustained multiple falls with one fall resulting in a head laceration that required staples. This example of non-compliance was cited at a HARM level. Additionally, a resident eloped from the facility and was located by police approximately 3-4 hours after leaving the facility and resident had multiple falls without new interventions identified to prevent future falls. Resident identifiers: 12, 13, and 15.Findings included:HARM1. […]

• Actual harm, isolatedF740Oct 3, 2024

  Based on interview and record review it was determined, for 1 of 28 sampled residents, that the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, a resident with a history of suicidal ideations (SI) was hospitalized for a suicidal attempt and did not have behavioral health services provided for more than 2 months after the hospitalization . […]

• No harm, potential for more than minimal, widespreadF727Oct 9, 2025

  Based on interview and record review, the facility did not use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Specifically, the facility did not always have a registered nurse at least 8 consecutive hours on certain weekends.Findings Included: Findings Included:The facility's staffing schedules from September 2025 to October 2025 were reviewed.-There was no RN scheduled on 9/14/25.-There was no RN scheduled on 9/28/25.On 10/8/25 at 2:58 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they did not need to have a registered nurse scheduled on every shift. The DON stated that they did not do admissions on the weekends and if the residents needed an assessment completed the nurse would call her. […]