Pine Forest Rest Home

The facility failed to ensure the implementation of physician's orders for one resident requiring weekly finger stick blood sugar (FSBS) checks. Records showed no FSBS data was collected or documented in the eMAR from March 2, 2024, through May 15, 2024, despite an order for weekly testing.

The facility failed to implement CDC and NC DHHS guidance regarding infection control during the COVID-19 pandemic. Specifically, staff and residents were not consistently wearing proper personal protective equipment (PPE), staff were not conducting required screenings, and social distancing was not maintained during communal activities.

The facility failed to implement CDC and NC DHHS guidance regarding infection control during the COVID-19 pandemic. Specifically, staff and residents were observed not wearing proper personal protective equipment, and staff were observed using cloth face coverings instead of medical masks. Additionally, the facility failed to ensure proper masking and social distancing protocols were maintained.

The facility failed to ensure that residents on therapeutic diets, specifically No Concentrated Sweets (NCS) diets, were served meals as ordered by their physicians. Evidence included serving items like chocolate cake, pudding parfaits, and fruit crisp that did not meet dietary restrictions, as well as providing whole milk and canned peaches in light syrup to a resident with diabetes.

The facility failed to ensure that all staff members had a criminal background check completed prior to their hire date. Specifically, a review of personnel records for two sampled employees revealed missing criminal background check documentation and lack of required consent forms.

The facility failed to verify that Staff A had no substantiated findings listed on the North Carolina Health Care Personnel Registry (HCPR). The Resident Care Coordinator was unaware that an HCPR check was required for all staff, mistakenly believing it only applied to medication aides.

The facility failed to ensure that 2 of 3 sampled staff members (Staff A and Staff C) were tested for tuberculosis disease using the required 2-step method. Personnel records showed only a single skin test for these employees, lacking the necessary second step within two weeks of hire.

The facility failed to ensure that 2 of 3 sampled staff members were tested for tuberculosis disease using the required 2-step method. Personnel records for Staff A and Staff C only showed documentation of a single skin test, failing to demonstrate the necessary second step of the testing protocol.