Pinecrest Manor

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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? MDS instructions for section K0300 indicated that if weight loss of five percent or more in the last month or loss of 10 percent or more in the last six months to code yes. The MDS instructions further indicated to calculate 10 % weight loss in 180 days, start with the resident's weight closest to 180 days ago. MDS instructions for section PO200 revealed to identify all alarms that were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Resident R7's clinical record revealed an admission date of 5/29/29, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Schizoaffective Disorder )a mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Manufacturer's guidelines for Trelegy Ellipta (medication used to treat Chronic Obstructive Pulmonary Disease [COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing] and Asthma [a long-term inflammatory disease of the airways that cause the airways to narrow and swell causing symptoms such as wheezing, coughing, chest tightness, and shortness of breath], indicated that Trelegy should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. Review of facility policy entitled Medication cart: Med Pass Guidelines dated 2/06/25, revealed that Multi-dose vials such as insulin must have either opened on date or used by date which should be checked prior to administration. Review of facility policy entitled Pharmaceutical Services and Medication Storage dated 2/06/25,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan for one of 23 residents reviewed (Resident R99). Findings include: A facility policy entitled, Care Plan: Baseline (IPOC) dated 2/06/25, revealed Baseline PCM IPOC will be entered and developed for each resident within 48 hours. Resident R99 's clinical record revealed an admission date of 1/09/25, with diagnoses that included diabetes, high blood pressure, anemia, and acute kidney injury. Resident R99 's clinical record lacked evidence that a baseline care plan was initiated for Resident R99. During an interview on 2/12/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the clinical record of Resident R99 lacked evidence that a baseline care plan was initiated. 28 Pa. Code 211.12(d)(1) Nursing services

Based on reveiew of clinical records, observations and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of seven of 23 residents interviewed (Residents R80, R12, R34, R37, R93, R79, and R51). Findings include: Independent interview on 2/10/25, at 4:13 p.m. revealed that Resident R51 disclosed that he/she cannot walk, uses an electric wheelchair for mobility, and requires a mechanical lift to transfer. Resident R51 shared that there are times (especially on off shifts and weekends) when he/she waits on the toilet for an hour to get help, and that he/she has waited so long to get to the bathroom, he/she soiled his/her clothing. Resident R51 also stated that staff will come in and turn off the bell, and not return. Interviews during the Resident Council meeting on 2/11/25, between 1:00 p.m. and 2:15 p.m. revealed that six out of six alert and oriented residents were in attendance (Residents R80, R12, R34, R37, R93, and R79) and reported concerns related to staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of clinical records and facility policy, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during wound care for one of 23 residents reviewed (Resident R13). Findings include: A facility policy entitled, Handwashing and Hand Hygiene dated 2/06/25, revealed that hand hygiene be performed after handling soiled equipment and after removing gloves. Resident R13's clinical record revealed an admission date of 3/15/22, with diagnoses that included Alzheimer's Disease (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), Venous stasis (a condition that occurs when blood doesn't flow properly from the legs back to the heart), and congestive heart failure (CHF- long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply). Observation of wound care on 2/12/25, at 9:27 a.m. revealed the following: Licensed Practical Nurse (LPN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to initiate a baseline care plan for one of 22 residents reviewed (Resident R201) and failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 22 residents reviewed (Resident R99). Findings include: A facility policy entitled, Care Plan: Baseline (IPOC) dated 2/21/24, stated Baseline PCM IPOC will be entered and developed for each resident within 48 hours. Resident R201 's clinical record revealed an admission date of 2/27/24, with diagnoses that included diabetes, high blood pressure, and peripheral arterial disease (narrowing of arteries, usually in the leg that result in reduced blood flow). Resident R201 's clinical record lacked evidence that a baseline care plan was initiated for Resident R201. During an interview on 3/13/24, at 1:23 p.m. the Nursing Home Administrator confirmed that the clinical record of Resident R201 lacked evidence that a baseline care plan was initiated. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 22 residents reviewed (Resident R7). Findings include: Review of facility policy entitled Care Plan: Interdisciplinary dated 2/21/24, stated 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, and formulate individualized treatment plans that promote maximum functioning and well-being and Nursing staff must notify RNAC (Registered Nurse Assessment Coordinator) of changes that could initiate new or additional care plans. Resident R7's clinical record revealed an admission date of 3/15/21, with diagnoses that included Alzheimer's Dementia (a group of symptoms affecting memory, thinking, and social abilities), Seizures, and High Blood Pressure. Resident R7's clinical record revealed a physician's order dated 5/30/23 indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and manufacturer's instructions, observation, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner for one of two medication rooms observed (Unit A/B medication room). Findings include: Review of facility policy entitled PPD [solution used for tuberculosis testing upon admission and for employment], Administration dated 2/21/24, revealed Discard bottle 30 days after opened. Review of manufacturer's recommendations for Tubersol PPD indicated that vials which are entered and in use for 30 days should be discarded. Observation of drug storage on 3/13/24, at approximately 11:12 a.m. in Unit A/B medication storage room refrigerator revealed and an opened vial of Tubersol PPD without an open date, therefore the staff were unable to determine the discard date. During an interview at that time, Licensed Practical Nurse Employee E2 confirmed that the opened Tubersol PPD vial lacked an open date and staff were unable to determine the discard date. 28. Pa.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.