Pine Crest Health and Memory Care

In the surveyor’s words

From the most serious findings on record at Pine Crest Health and Memory Care, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF627Jun 4, 2026

  Based on interview and record review, the facility did not have policies in place to provide residents a written notice of transfer to include reason for transfer, Ombudsman contact information, and appeal rights. This has the potential to affect all 93 residents.This is evidenced by:On 06/03/26, Surveyor requested the facility's transfer notice policy. Surveyor reviewed the facility's policy and noted no protocol to provide residents a written transfer notice that states the reason for the transfer, Ombudsman contact information, and appeal rights.On 06/03/26 at 2:51 PM, Surveyor interviewed Director of Nursing (DON) B regarding written transfer notices. […]

• No harm, potential for more than minimal, widespreadF628Jun 4, 2026

  Based on interview and record review, the facility did not provide residents a written notice of transfer that includes reason for transfer, Ombudsman contact information, and appeal rights to 10 of 10 residents (R7, R17, R8, R14, R99, R6, R83, R3, R96, and R101) reviewed.R7 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R17 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R8 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R14 was transferred to the hospital on 2/21/26. A written notice of transfer was not completed.R99 was transferred to the hospital on [DATE] and 04/15/26. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 93 of 93 residents.-Surveyor observed an opened bag of cauliflower and an open bag of chopped celery were not dated with an expiration date, an open date, or a use by date.-Surveyor observed several individual uncovered bowls of lettuce without a date identifying when they were prepared. […]

• No harm, potential for more than minimal, widespreadF880Jun 4, 2026

  Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 93 residents (R.) -The facility's measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems are not being performed based on nationally accepted standards and in accordance with their Water Management Program and the facility does not demonstrate they have system in place to monitor the control measures as indicated. -The facility did not disinfect equipment used during wound cares for R3. […]

• No harm, potential for more than minimal, widespreadF880Feb 10, 2022

  Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection, such as COVID-19, which had the potential to affect all residents of the facility. Throughout the survey, observations were made in which: - staff did not wear appropriate Personal Protective Equipment (PPE) such as N95 masks in resident care areas in which residents that are suspected or positive for Covid-19 reside; - isolation bins that are placed outside resident rooms did not contain the proper PPE (for example N95 masks); - sanitizing wipes for staff to wipe down protective eyewear were not available outside rooms in which residents that are suspected or… […]