Pinecrest Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Pinecrest Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Mar 13, 2025

  Based on observations, interviews and record review facility failed to ensure proper storage of medication and biologicals for five residents (Residents #381, #62, #47, #12 and #65) as evidenced by observations of bottled pills inside a plastic bag at Resident 381's bedside, a bottle labeled Zicam (cold remedy) at the Resident # 62's bedside, a tube labeled Zinc Oxide Ointment at the Resident#12's bedside two bottles labeled Acetic Acid Irrigation Solution at Resident # 47's bedside and a bingo card of discontinued medication for Resident#65. There were 83 residents residing in the facility at the time of survey. The findings included: On 03/10/25 at 7:43 AM Resident #381 was observed in bed . A plastic bag of bottled pills was observed on the nightstand next to the resident. […]

• No harm, potential for more than minimal, isolatedF583Mar 13, 2025

  Based on observations, record reviews and interviews, the facility failed to ensure residents' personal information was kept private as evidenced by observations of paperwork containing residents' information left visible and unattended in a public area. The findings included: Observation on [DATE] at 7:18 AM, while walking through the Northside Nursing station, revealed a demographic sheet with resident's information visible and unattended on top of the counter. (See attached photo) On [DATE] at 7:24 AM, Staff I, Licensed Practical Nurse (LPN), approached the station and was informed about the demographic sheet. When asked about the facility's protocol for keeping residents' information private, Staff I, LPN, replied, No resident information should be visible. […]

• No harm, potential for more than minimal, isolatedF755Mar 13, 2025

  Based on observations, interview and record reviews the facility failed to ensure a routine breathing medication was reordered and received in a timely manner for one resident (Resident #48) with a diagnosis of Seizure and Asthma, out of three sampled residents as evidenced by an Inhalation medication for Asthma unavailable at prescribed time. The findings included: On 03/12/25, at 9:13 AM, Staff A, Licensed Practical Nurse (LPM) was asked to verify whether all prescribed medications for Resident #48 were in stock. Staff A, LPN revealed that the inhaler asthma was not available at that time. During an interview, Staff A, LPN stated, I reordered the inhaler on March 10,25. […]

• No harm, potential for more than minimal, isolatedF759Mar 13, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure their medication error rate were 5% or lower as evidenced by an error rate of 13.89 % out of 36 opportunities. There were 83 residents residing in the facility at the time of survey. The findings included: On 03/11/25 at 11:07 AM, a medication observation was completed with Staff B, LPN on the North medication cart#4 for Resident#379. Staff B, LPN revealed Resident #379 takes medicine by mouth in a whole form. […]

• No harm, potential for more than minimal, isolatedF609Oct 12, 2023

  Based on record review and interview, the facility failed to implement policies and procedures for ensuring the timely reporting of abuse and an injury of unknown origin resulting in serious bodily harm for 2 out of 23 sampled residents (Resident #140 and Resident #389) The findings included: 1. Review of the facility's abuse investigative five day report revealed, On March 8, 2023, at approximately 10:30 AM, Resident #140's assigned nurse called the nursing supervisor from Resident #140's room to come immediately. The investigative report indicated that upon the nurse supervisor arrival to the room, Resident #140 told the nursing supervisor that she was verbally abused by one of the certified nurse assistants (CNA) of the night shift (11:00 PM to 07:00 PM). […]