Pine Crest Health Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 10, 2026

  Based on observation, interview, video review, and record review, the facility failed to ensure one resident (R4) remained free from physical abuse by staff. This failure resulted in R4 being pushed in the chest causing R4 to fall back into the chair and being slapped repeatedly to prevent R4 from standing up. This failure affected one of four residents (R4) reviewed for abuse and had the potential to affect 152 residents residing in the facility.The Immediate Jeopardy began on 06/18/26 when V18, Certified Nursing Assistant (CNA) physically pushed R4 in the chest causing R4 to fall into a chair then slapped R4's hands in an attempt to stop R4 from standing up. […]

• Immediate jeopardy, isolatedF689Aug 7, 2025

  Based on interview and record review the facility failed to have a system in place to prevent unauthorized and unsupervised leave from the facility. This failure resulted in one resident's (R1) elopement from the facility without staff knowledge who has documented assessments related to elopement/wandering behaviors.This was identified as an immediate jeopardy which begin on 07/17/25 at 8:55pm when R1 eloped from the facility without supervision and authorization.V1 (Administrator) was informed of the immediate jeopardy and a template was presented on 07/28/25.On 08/04/25 acceptable removal plan was received after revision of the original plan submitted on 7/28/25.The Immediate Jeopardy was removed on 08/04/25, however, the non-compliance remains at the level two because additional time is… […]

• Immediate jeopardy, isolatedF689May 3, 2023

  Based on interview and record review, the facility failed to prevent a resident (R1) from obtaining a severe burn from a radiator heater connected to the wall when R1's bed was pushed against the wall for one out of three residents reviewed for accidents and incidents in a total sample of four. This failure resulted in R1 suffering second and third degree burns to the left leg requiring a hospitalization where R1 received a debridement and skin graft surgery. The Immediate Jeopardy that began on 3/19/23 was removed on 3/21/23 when the facility removed the heater on the wall from R1's room. The administrator was notifed on 04/14/23. This past non-compliance occurred from 03/19/23 through 03/21/23. […]

• Actual harm, isolatedF600Sep 18, 2025

  Based on interview and record review, the facility failed to follow its abuse policy by not ensuring that residents were free from physical and verbal abuse. This affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R1 experiencing, a facility staff member directed inappropriate and profane language toward R1. R1 reported feeling disrespected, childlike, and angry as a result of the interaction. This also resulted in (R2) experiencing a facility staff member struck R2 on the head. Using the reasonable person concept, this action would cause a R2 to feel fear and intimidation. Findings Include: R1's brief interview for mental status dated 8/26/25 documents a score of fifteen which indicates cognitively intact. […]

• Actual harm, isolatedF689Aug 14, 2025

  Based on interview and record review, the facility failed to monitor and provide effective supervision to ensure that a resident with a history of alcohol abuse was able to get access to alcohol while in the facility. This affected one resident (R143) reviewed for supervision and monitoring. This failure resulted in R143 being able to obtain alcohol on two separate occasions in the resulting hospitalizations. [NAME], [NAME] (143) OLADINI, BOSEDE (32338) - Hazards/SupervisionR1's records show the following:Face sheet shows that R143 was admitted to the facility on [DATE] with diagnoses which include but are Alcohol Abuse, Opioid Abuse, Bipolar Disorder, Schizoaffective Disorder, Hypertension, Acute Kidney Failure, And Acute Respiratory Failure.Progress notes dated 6/6/25 at 6:55pm written… […]