Pine Crest Guest Home Inc

In the surveyor’s words

From the most serious findings on record at Pine Crest Guest Home Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 16, 2025

  Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when the facility failed to obtain immediate medical assistance for Resident #1 who sustained a fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van and was not assessed by licensed personal for approximately thirty (30) minutes during transport for one (1) of four (4) sampled residents (Resident #1). On [DATE] Resident #1 was transported to an appointment by the Administrator in a wheelchair at 1:06 PM without assistance from a nurse or Certified Nursing Assistant (CNA). […]

• Immediate jeopardy, isolatedF689Jun 16, 2025

  Based on observation, interview, and record review, the facility failed to protect a resident from accidents hazards when the facility failed to obtain immediate medical assistance when a resident sustained a fall from a wheelchair in the facility van and was not assessed by licensed personnel for approximately 42 miles while being transported back to the facility while lying on the floor for one (1) of four (4) sampled residents. (Resident #1). The facility's failure to ensure Resident #1 was properly secured and transported safely, under trained supervision, resulted in her fall from a wheelchair in the facility van. Resident #1 was transported back to the facility while lying on the floor of the facility van for approximately 42 miles and arrived back at the facility at 2:40 PM. […]

• No harm, potential for more than minimal, patternF584Dec 12, 2024

  Based on observation, interviews and record review the facility failed to maintain a safe and clean environment related to a leaking roof, damaged ceiling tiles, and thick, black, wet biological growth in air vents for two (2) of three (3) days of observation Findings included: On 12/10/2024 at 10:30 AM, during an observation and interview, Resident #35's room was observed to have a leaking roof near the entranceway, with a blanket draped on the floor. Resident #35 reported that the ceiling was leaking from the light fixture in the entranceway to his room but stated the leaks were not near his bed or where he sits to watch TV. On 12/10/2024 at 10:37 AM, during a facility-wide observation, leaks were observed at various spots throughout the ceiling. […]

• No harm, potential for more than minimal, isolatedF565Dec 12, 2024

  Based on observation, interviews, record review, and policy review, the facility failed to resolve resident council members' complaints regarding the lack of hot water in a timely manner for one (1) of two (2) halls. Findings included: A review of the facility's policy titled, Conflict Resolution and Resident Complaint and Grievance Process, dated 09/06/2022, revealed, It is this facility's commitment to safe, respectful, and high-quality care, all concerns brought to the organization's attention by residents/legal representatives shall be reviewed in a timely manner. This organization shall respond to such concerns in a timely, reasonable, and consistent manner. […]

• No harm, potential for more than minimal, isolatedF690Aug 10, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide the appropriate care and services to ensure a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections for one (1) of two (2) residents reviewed with indwelling catheters. Resident #44 Findings include: On 8/08/23 at 10:47 AM, an observation revealed Resident #44 sitting up in his recliner with an indwelling drainage catheter bag attached to the bed. […]