A list of the most recent deficiencies for Pinecrest Medical Care Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-16 | 2024-02-06 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-27 | 2023-09-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-07-27 | 2023-09-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-07-27 | 2023-09-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2023-07-19 | 2023-09-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-27 | 2023-08-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-27 | 2023-08-23 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-07-27 | 2023-08-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-07-27 | 2023-08-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-07-27 | 2023-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-27 | 2023-08-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-27 | 2023-08-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-27 | 2023-08-23 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-27 | 2023-08-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-27 | 2023-08-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-27 | 2023-08-23 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-07-27 | 2023-08-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-27 | 2023-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-23 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-27 | 2023-08-23 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-07-27 | 2023-08-23 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-27 | 2023-08-23 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-27 | 2023-08-23 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-07-27 | 2023-08-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-16 | 2022-08-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-16 | 2022-07-21 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-16 | 2022-07-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-16 | 2022-07-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-06-16 | 2022-07-21 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-06-16 | 2022-07-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-16 | 2022-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-07-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-23 | 2022-03-31 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-03-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-08 | 2022-01-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-21 | 2021-11-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-21 | 2021-11-12 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2021-03-09 | 2021-05-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-09 | 2021-05-19 | N |
| Respond appropriately to all alleged violations. | Health | 2021-03-09 | 2021-05-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-03-09 | 2021-05-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-07 | 2021-05-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-07 | 2021-05-07 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-04-07 | 2021-05-07 | Y |
