Pinebrook Residential Center II

The facility failed to ensure that the required written notice and hearing request forms were properly completed and delivered to residents or their responsible persons. Specifically, the facility must ensure the Notice of Discharge includes all required elements and is hand-delivered with a receipt requested or sent via certified mail on the same day it is dated.

The facility failed to ensure residents were treated with dignity and respect and were free from physical and verbal abuse. Specifically, Staff A was observed striking a resident with a rubber band and forcefully dragging the resident's wheelchair through the rain, resulting in property damage and the resident feeling unsafe.

The facility failed to ensure the clarification or verification of medication and treatment orders for 2 of 3 sampled residents. Specifically, the facility did not verify discrepancies in sliding scale insulin parameters for Resident #1 between different physician orders.

The facility failed to provide necessary personal care assistance for several residents. Specifically, two residents required assistance with bathing and grooming but were not provided care, and others who refused care were not properly managed. Evidence included a resident admitted to the hospital with severe hygiene neglect, including being visibly soiled and having skin peeling from his feet.

The facility failed to provide necessary personal care assistance for 2 of 6 sampled residents. Specifically, staff failed to assist residents with bathing, dressing, and grooming/hygiene, even when residents refused care or when documentation was missing.

The facility failed to ensure a serving of milk or a dairy alternative was offered and served to residents at every meal. Observations and interviews revealed that staff often only provided milk upon resident request and, on certain days, failed to offer any dairy products at all. This lack of consistent service was linked to inadequate milk inventory and staff unawareness of dietary requirements.