The Greens at Pinehurst Rehabilitation & Living Ce

In the surveyor’s words

From the most serious findings on record at The Greens at Pinehurst Rehabilitation & Living Ce, in the surveyor’s own words.

• Immediate jeopardy, patternF756Jul 20, 2022

  Based on record review and interviews with the Pharmacy Consultant and the staff, the facility's Pharmacy Consultant failed to identify and to report drug irregularity to the Director of Nursing and or the Attending Physician regarding the facility's failure to transcribe and to administer the [MEDICATION(S)] (antiseizure medication) to a resident as ordered upon readmission from the hospital (Resident #175). Resident #175 was discharged to the hospital on 11/9/21 due to possible stroke like symptoms and tremors and was readmitted back to the facility on [DATE] with a diagnosis of [CONDITION(S)] and was prescribed [MEDICATION(S)]. [MEDICATION(S)] was not transcribed by the admitting Nurse and therefore was not administered to the resident from 11/14/21 through 3/3/22. […]

• Immediate jeopardy, patternF760Jul 20, 2022

  Based on record review and interview with the Nurse Practitioner and the staff, the facility failed to administer the [MEDICATION(S)] (an antiseizure medication) to a resident as ordered from the hospital (Resident #175). Resident #175 was discharged to the hospital due to tremors and altered mental status on 11/9/21 and was discharged back to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #175 did not receive the [MEDICATION(S)] from 11/14/21 through 3/3/22 and on 3/4/22, Resident #175 had [CONDITION(S)] activity and was sent to the emergency room . The resident had received a dose of [MEDICATION(S)] and [MEDICATION(S)] (intravenous) [MEDICATION(S)]. Resident #175 was readmitted back to the facility on [DATE]. […]

• Actual harm, isolatedF686Sep 28, 2023

  Based on record reviews and interviews with staff, Physician Assistant (PA), Wound Nurse Practitioner, and Medical Director (MD), the facility failed to implement preventative measures for a resident assessed to be moderate to high risk for development of pressure ulcers. The resident developed a deep tissue injury to the sacrum, 2 deep tissue injuries to the left lateral foot, as well as a deep tissue injury to the left ankle. Deterioration of the sacral wound was not communicated to the MD or the PA. The resident was admitted to the hospital with septic shock for 1 of 8 residents (Resident #178) reviewed for pressure injuries. […]

• Actual harm, isolatedF697Jul 20, 2022

  Based on resident, staff, Consultant Pharmacist, Pharmacist #1, Nurse Practitioner (NP) and Medical Director (MD) interviews, observations and record review, the facility failed to obtain and administer prescribed medications to treat pain for a newly admitted resident (Resident #171) with a left acetabulum (the socket part of the hip ball and socket joint) fracture and a pelvic fracture. This lack of pain medication resulted in observed evidence of pain and a reported pain numerical level of 10 out of 10. This was for 1 of 2 residents reviewed for pain. The finding included Resident #171 was admitted on [DATE]. There was no Minimum Data Set (MDS) assessment information except for the entry MDS and there was no documented evidence of a baseline care plan. […]

• Actual harm, isolatedF726Jul 20, 2022

  Based on staff interviews and record review, the facility failed to ensure 2 (Nurse #1 and Nurse #2) of 3 agency nurses interviewed were oriented to the facility processes and procedures regarding the following: contacting the on-call medical provider on the weekends, how to activate the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 (Resident #171) of 2 residents reviewed for pain. This resulted in uncontrolled pain for Resident #171 admitted with multiple fractured areas of his pelvis. […]