Pineknoll Rehabilitation Centre

In the surveyor’s words

From the most serious findings on record at Pineknoll Rehabilitation Centre, in the surveyor’s own words.

• Actual harm, isolatedF689May 26, 2022

  Based on interview and record review the facility failed to provide supervision for a cognitively impaired dependent resident while in the bathroom for 1 of 3 residents reviewed for falls. This deficient practice resulted in the resident being left in the bathroom alone and sustaining a fall causing a laceration to the forehead and a fracture of the C1 vertebral body. (Resident B) Findings include: The clinical record for Resident B was reviewed on 5/25/2022 at 10:08 a.m. Diagnoses for Resident B included, but were not limited to, [CONDITION(S)], hypo-osmolality, [CONDITION(S)], hypertension, muscle weakness, and repeated falls. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 4/16/2022, was reviewed on 5/25/2022 at 10:08 a.m. […]

• No harm, potential for more than minimal, widespreadF812Apr 19, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was prepared and distributed in a safe, sanitary manner. This deficient practice had the potential to impact 55 of 55 residents who received meals from the facility kitchen. Findings include: During a kitchen tour on 4/15/24 at 10: 15 a.m., accompanied by the Dietary Manger, the following concerns were observed: a. Varied sizes of empty boxes were on the floor in front of the three compartment sink. b. A 1/4 sized shallow steam table pan, in the clean storage, had a baked on brownish-black sticky residue on the pan lip and descending into the food contact area. Three pea-sized spots of dark residue were on the food contact surface. c. […]

• No harm, potential for more than minimal, patternF839May 27, 2025

  Based on interview and record review, the facility failed to ensure a nurse, who was employed to work in the facility in the nursing department, had a valid Indiana nursing license (LPN 3). This deficient practice had the potential to impact 56 of 56 residents who resided in the facility. Finding include: Employee records were reviewed on 5/22/25. Licensed Practical Nurse (LPN) 3 was listed on the Employee Records form, which was completed by the facility. The form indicated the employee's job title as LPN. The form indicated the nurse had been employed by the facility since 6/20/24. The facility's provided a binder containing nursing licenses verification, for facility employees. […]

• No harm, potential for more than minimal, patternF880Feb 20, 2023

  A. Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 by ensuring infection prevention and control strategies were utilized during a facility COVID-19 outbreak, including failure to follow infection control guidelines upon entering and leaving rooms under transmission-based precautions, and during medication administration. Findings include: 1. During an interview at entrance conference, on 2/14/23 at 9:41 a.m., the Administrator indicated the facility was in a COVID-19 outbreak. […]

• No harm, potential for more than minimal, patternF881Feb 20, 2023

  Based on interview and record review, the facility failed to implement their antibiotic stewardship program for antibiotic use for 5 of 10 residents prescribed antibiotics for urinary tract infections in December 2022 and January 2023. (Residents 43, 16, 22, 27, and 253) Findings include: The facility infection surveillance records were reviewed on 2/17/23 at 10:36 a.m., and indicated the following: a. Resident 43 was prescribed amoxicillin/clavulanate potassium (antibiotic) 875 - 125 milligrams (mg) twice a day for 10 days for a suspected urinary tract infection. A urinalysis (U/A) with a culture and sensitivity (C&S) was completed. The C&S indicated no growth (no laboratory evidence of urinary tract infection). […]