Pine Knoll Nursing Center

In the surveyor’s words

From the most serious findings on record at Pine Knoll Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, patternF688Mar 2, 2026

  Based on observations, interviews, and record review, the facility failed to ensure three Residents (#24, #6, and #11) received appropriate treatment and services to prevent a decrease in range of motion. Specifically:1.For Resident #24, the facility failed to implement interventions to prevent a new contracture of the left fifth finger from developing and then worsening resulting in the amputation of this left fifth finger. The facility failed to:1a.) Ensure Occupational Therapy (OT) evaluated Resident #24 timely and provided therapy at the frequency ordered. […]

• Immediate jeopardy, patternF600Sep 26, 2024

  Based on record review and interview, the facility failed to protect three Residents (#20, #23, #26), from neglect, out of a total sample of 26 residents. Specifically, 1. For Resident #20, the facility neglected to a.) implement wound treatments as recommended by the Consultant Wound Physician resulting in the deterioration of a closed unstageable pressure injury to a Stage 4 pressure injury and b.) failed to follow up on a progress note indicating right hip redness dated 8/28/24, and implement the use of an air mattress. 2. For Resident #23, the facility neglected to implement treatment recommendations by the Wound Consultant Physician for wound care. 3. […]

• Immediate jeopardy, patternF686Sep 26, 2024

  Based on observations, interviews, and record review, the facility failed to provide care and treatment to prevent the development and worsening of pressure injury's (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the coccyx, hips, heels, or elbows) for three Residents (#20, #23, and #26) out of a total sample of 26 residents. Specifically, 1a. For Resident #20 the facility failed to implement treatments and physician orders recommended by the Consultant Wound Physician resulting in the wound requiring antibiotic therapy resulting in the deterioration of an unstageable pressure wound progressing to a Stage 4 pressure injury. 1b. […]

• Immediate jeopardy, patternF726Sep 26, 2024

  Based on observation, record review, and interviews the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skill sets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1. Ensure licensed nursing staff were trained and demonstrated clinical competency related to pressure injury/wound care, including recognizing and reporting wound deterioration, evaluation and measurements for one resident (#20), out of a total sample of 26 residents. […]

• Immediate jeopardy, patternF835Sep 26, 2024

  Based on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1. Provide nursing staff education and training to provide competent, safe, and effective wound care management. 2. Provide continuation of the pressure injury prevention and care services following the absence of the Director of Nursing (DON) and implement an effective system for pressure injury (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. […]