Pinecrest Manor

In the surveyor’s words

From the most serious findings on record at Pinecrest Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF565Jul 20, 2026

  Based on review of facility policy, facility documents, and resident and staff interviews, it was determined that the facility failed to correct Resident Council concerns for a period of three months (April 2026 through June 2026). Findings: Review of facility policy, Resident Council, dated 11/18/25, indicated Staff is to follow up with any of the residents' concerns that were voiced at the meeting so they can be addressed at the next meeting. Review of facility policy, Dining Room, dated 11/18/25, indicated, To promote a home-like environment and enhance socialization. […]

• No harm, potential for more than minimal, patternF641Jan 30, 2026

  Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of five of 24 residents reviewed (Residents R94, R30, R105, R70, and R42).Findings include: MDS instructions for section J Health Conditions, Subsection J1800 Any Falls Since Admission/Entry or Reentry or Prior Assessment indicated Has the resident had any falls since admission/entry or reentry or the prior assessment whichever is more recent? […]

• No harm, potential for more than minimal, patternF761Feb 13, 2025

  Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store schedule II-V medications in a separately locked, permanently affixed compartment in three of four medication rooms reviewed (A/B, C/D and E/F); the facility failed to prevent the opportunity for potential unauthorized access of medications on two of four medication carts observed (D and F); and the facility failed to appropriately discard outdated medications for one of four medication carts reviewed (E wing). Findings include: Review of facility policy entitled Narcotic Policy PCM dated 2/06/25, revealed Schedule II-V medications are stored in a permanently affixed, double-locked compartment separate from all other medications. […]

• No harm, potential for more than minimal, isolatedF656Jan 30, 2026

  Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 24 residents reviewed (Resident R7).Findings include: Review of facility policy dated 11/18/25, entitled Care Plans: Interdisciplinary indicated the purpose is to provide a comprehensive care plan that includes measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs that are identified including those identified in the comprehensive assessment. The policy further stated that care plans will be reviewed quarterly and for significant changes and hospital returns as well as staff updating as required between care plan conferences. […]

• No harm, potential for more than minimal, isolatedF761Jan 30, 2026

  Based on review of facility policy and drug manufacturer instructions, observation, and staff interview, it was determined that the facility failed to appropriately date and store medications in one of four medication carts reviewed (C Hall Medication Cart). Findings include: Review of facility policy dated 11/18/25, entitled Pharmaceutical Services and Medication Storage revealed the facility must adhere to all relevant state, federal, and local regulations, included those from the Department of Health, Food and Drug Administration, and Drug Enforcement Agency and State Boards of Pharmacy regarding the storage, handling, and administration of all medications. […]