Pinecrest Medical Care Facility

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jan 7, 2021

  Based on observation, interview, and record review, the facility failed to prevent and contain COVID-19 by failure to: 1. Perform proper staff entrance screenings, including hand hygiene and cleaning and disinfection of reusable medical equipment. 2. Limit staff entrance screening locations. 3. Perform Resident Line-Listing COVID-19 infection surveillance. 4. Complete staff illness surveillance. 5. Report accurate and timely COVID-19 staff positivity data to the local Health Department. 6. Follow transmission-based precautions (TBP), Personal Protective Equipment (PPE), and signage. 7. Adequately monitor staff for infection control practices during a COVID-19 outbreak. 8. Ensure staff maintained six feet social distancing. 9. […]

• Actual harm, isolatedF686Jul 27, 2023

  This deficiency pertains to Intakes: MI00132367 and MI135306. Based on observation, interview, and record review, the facility failed to provide treatment and services to promote healing of pressure ulcers, including one Stage 3 pressure injury which resulted in harm, for three Residents (R42, R17 and R68) of four residents reviewed for pressure ulcer care. This deficient practice resulted in delayed wound healing, worsening of condition, and increased risk of infection. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. R42 During a wound care observation on 7/26/23 at 8:17 a.m., Registered Nurse (RN) GG emptied the contents of a clear plastic bag on the prepared overbed table in R42's room. […]

• Actual harm, isolatedF760Apr 7, 2021

  Based on interview and record review, the facility failed to prevent a significant medication error for one Resident (#10) of four residents reviewed for medication errors. This deficient practice resulted in harm when Resident #10 developed severe respiratory distress, became unresponsive and required emergency transfer to the hospital. Finding include: All time recorded in Easter Standard Time (EST), unless otherwise noted. This citation pertains to Intakes MI 727 and MI 926. Resident #10 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF563Jan 7, 2021

  Based on interview and record review, the facility failed to provide scheduled telephone and virtual video visitation during COVID-19 pandemic nursing home visitor restrictions for three Residents (#1, #2, & #8) out of five residents reviewed for resident rights. This deficient practice resulted in psychosocial harm, based upon a reasonable person standard, increased isolation, decreased family support, and feelings of sadness and loneliness for the Residents and families. Findings include: All times noted are Eastern Standard Time (EST). During an abbreviated survey, conducted 12/30/20 through 1/7/21, a complaint allegation of facility failure to facilitate virtual visits with family members was investigated. […]

• No harm, potential for more than minimal, widespreadF880Jul 25, 2024

  All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program in accordance with facility policies to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Document signs and symptoms of infections. 2. Conduct departmental surveillance for adherence to infection control practices. 3. Handle meal trays for residents in transmission-based precautions in accordance with facility policy. 4. Provide barriers for insulin pens during medication administration. 5. […]