Pinecrest Retirement Community

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Residents #26, Resident #4, and Resident #8) and 4 of 7 staff (CNA H, LVN C and CNA F, and CNA G) reviewed for infection control.The facility failed to ensure CNA H followed infection control measures during dining service on 7/06/2026.The facility failed to ensure CNA H properly handled soiled linens and clothing for Resident # 26 on 7/06/2026.The facility failed to ensure CNA H properly cleaned Resident #26's soiled wheelchair cushion on 7/06/2026.The facility failed to ensure LVN C properly cleaned a glucometer (used to check blood sugars) or use a barrier for her supplies when she checked the blood sugar of Resident #4 on 7/7/2026.The facility failed to ensure CNA F and CNA G followed…

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 observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 2 medication storage rooms (The Arbors) reviewed for pharmacy services.The facility failed to remove expired influenza vaccines from the refrigerator in the medication room in The Arbors on 7/7/2026.These failures could place residents at risk for the unsafe administration of medications, not receiving prescribed doses of ordered medications and not receiving the intended therapeutic benefit of the medications.Findings include:During an observation on 7/7/2026 at 10:41 am, LVN A was in the medication room for The Arbors. The refrigerator revealed (3) boxes of influenza vaccine for 2025-2026 lot #AX615A that expired 6/30/2026.During an interview on 7/7/2026 at 10:41 am, LVN A said the nurses were responsible for checking the medication rooms and should be done daily. She said she was not aware the medication room had flu vaccines that were expired. She said…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 4 (Residents #42) residents reviewed for thickened liquid diets.The facility failed to ensure Resident #42 was not served thin liquids on 7/06/2026.This failure could place residents who received thickened liquid diets at risk of difficulty swallowing, possibly resulting in choking. Findings Included:Record review of Resident #42's facility face sheet, dated 07/06/2026, indicated Resident #42 was a [AGE] year-old male, admitted [DATE], with diagnosis of Dysphasia (difficulty with swallowing).Record review of Resident #42's admission MDS assessment, dated 06/08/2026, revealed a BIMS score of 14 that indicated Resident #42 had intact cognition. He required assistance with his ADLs.Record review of Resident #42's comprehensive care plan, dated 6/16/2026, indicated Resident #42 required a therapeutic diet related to…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 2 of 5 staff (CNA A and CNA B) reviewed for competent nursing care.The facility failed to ensure CNA A and CNA B were able to demonstrate competency in the skill of hand hygiene when they failed to perform hand hygiene and change their gloves during incontinent care provided to Resident #8 on 2/18/2026.These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.The findings included:Record review of an admission Record for Resident #8 dated 2/18/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart's inability to pump effectively), anemia…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #8) reviewed for infection control.The facility failed to ensure CNA A and CNA B followed contact precautions, changed their gloves, and did not touch clean items with dirty gloves when incontinent care was provided to Resident #8 on 2/18/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #8 dated 2/18/2026 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic systolic heart failure (the heart's inability to pump effectively), anemia (decreased red blood cell production), and osteoporosis…

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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen and 3 of 3 satellite kitchens (HC Arbor, HC Woodlands, Rehab). The dietary staff did not accurately test and log the dish machine for hot water sanitizing on 06/01/25 and the morning of 06/02/25. DA B served food without taking the holding temperatures on the rehab unit. Cook C did not take holding temperatures in the main kitchen on the foil covered plates and on any of the alternate food items. DA D served food whose temperatures were below appropriate holding temperatures on HC Arbor. She did not take temperatures on all 4 foil covered plates with food items. DA D used gloved hands to serve rolls, French fries, chicken strips, and onion rings after handling other items in the satellite kitchen on HC Arbor. DA E did not take holding temperatures on the alternate food items on HC Woodlands before serving. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings…

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 observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's main kitchen observed for kitchen sanitation. The soda drink dispenser had undated (date when opened) and expired soda syrup concentrates connected and available to be served. The freezer had open to air, improperly labeled and expired foods. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation and interview on 04/29/2024 at 09:20 am of the drink dispenser, 6 containers of concentrated soda syrup connected to dispenser had no opened date documented. Container of concentrated lemon soda expired 3/20/2024, container of concentrated root beer expired 4/18/2024, and a container of diet coke expired 09/10/2023. All three containers were connected to the dispenser and available to serve. The Dining Director said he had worked at the facility for two months and he was responsible for ensuring all expired items were discarded. The…

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 interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 3 of 28 dietary staff (Dietary Staff D, E and F) reviewed for reviewed for food and nutrition services. The facility did not ensure Dietary Staff D, E and F had a current food handlers' certificate while working in the facility's kitchen on 04/29/24 to 05/01/2024. This failure could place all residents who consumed food prepared from the kitchen at risk of food-borne illness. Findings included: Record review of 28 Dietary Staff food handlers' certificates indicated Dietary Staff D hire date 06/09/2022, Dietary Staff E hire date 10/29/2021 and Dietary Staff F hire date 10/01/2020 did not have a food handler's certificate. During an interview on 05/01/24 at 08:40 am, the Dining Director said that the three dietary employees did not have a current certificate. He said he had spoken with all three employees on 05/01/24, and they had informed him that they had no current food handler's certification .…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 6 residents (Residents #6) reviewed for MDS assessment accuracy. The facility incorrectly coded Resident #6 as having restraints on her MDS assessment. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: Record review of an admission Record dated 4/29/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses s of dementia (a group of thinking and social symptoms that affect activities of daily life), anemia (low red blood cells that carry oxygen in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #6 indicated she had severe impairment in thinking with a BIMS score of 00. She required substantial/maximal assistance to partial/moderate assistance with ADL's. She was always…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 12 residents (Resident #196) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission on Resident #196 and provide a care plan summary to the resident or representative. This failure could place residents at risk of not receiving correct and/or necessary care/treatment. Findings: Record review of a facility face sheet dated 4/30/2024 indicated Resident # 196 was a [AGE] year old male and admitted on [DATE] with a diagnosis of aftercare for femur fracture (broken upper leg). Record review of a baseline care plan indicated Resident # 196 was admitted on [DATE] and the baseline care plan was not completed until 4/18/2024 and the family was not provided a summary of the baseline…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 4 residents reviewed for accidents. (Resident #37) On 4/04/2024 CNA G failed to ensure a safe transfer by leaving Resident #37 standing in the sit to stand lift unattended and left the room to retrieve supplies and Resident #37 fell. This failure could place residents who required supervision at risk of injury or accidents and hospitalization. Findings included: 1.Record review of Resident #37's face sheet dated 4/29/2024 indicated she was an [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included: urinary tract infection, history of falling, muscle weakness, and dementia (impaired ability to remember, think, or make decisions). Record review of the significant change MDS dated [DATE] indicated Resident #37 had clear speech and makes self-understood. Resident #37's BIMS was 03 indicating severe cognitive impairment. Resident #37 required…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 2 resident personal refrigerators reviewed for food safety (Resident #9). The facility failed to ensure the refrigerator for Resident #9 did not contain expired cheese sticks, prune juice, or nutritional shakes. This failure could place resident at risk for food borne illnesses. Findings include: Record review of Resident #9's face sheet dated 4/30/2024 revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: scoliosis (a sideways curve of the spine), chronic pain, and anemia (low red blood cells). Record review of Resident #9's quarterly MDS dated [DATE] indicated Resident #9's BIMS was 15 indicating no cognitive impairment. Record review of Resident #9's care plan dated 11/08/2022 indicated: Elder chooses to have a refrigerator in his room and is able to monitor the temperature and cleanliness daily with…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 10 residents (Resident #6) and 1 of 8 staff (CNA A) reviewed for infection control. CNA A did not sanitize/wash hands between glove changes when providing incontinent care on 4/29/2024. This failure could place residents at risk for exposure to and transmission of diseases and infections. Findings included: Record review of an admission Record dated 4/29/2024 for Resident #6 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (a group of thinking and social symptoms that affect activities of daily life), anemia (low red blood cells that carry oxygen in the body), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE]…

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.