Pinecrest Gardens

The facility failed to maintain an environment free of hazards by leaving personal care products and disposable razors accessible to residents with dementia. Specifically, various hygiene products and an unidentified liquid in a milk jug were left on an open shelf in a common bathroom. This created a risk of ingestion or accidental injury for residents with wandering behaviors.

The facility failed to maintain an environment free of hazards by leaving personal care products and double-blade disposable razors accessible to residents with dementia. Specifically, various hygiene products and an unidentified liquid in a milk jug were found on accessible shelves in a common bathroom. Additionally, the facility lacked a written policy for the storage of personal care products on the back hall unit.

The facility failed to ensure health care referral and follow-up for a resident following a hospitalization. Specifically, the facility did not schedule a required follow-up appointment with a cardiology provider for a resident diagnosed with heart arrhythmia and heart block.

The facility failed to ensure health care referral and follow-up for a resident following a hospitalization. Specifically, the facility did not schedule a required follow-up appointment with a cardiology provider for a resident with new diagnoses of heart arrhythmia and heart block.

The facility failed to ensure medications were administered as ordered for several residents during medication passes. This included errors in administering controlled substances, eye drops, topical gels, and supplements, such as failing to allow the required 3 to 5-minute interval between different eye drop instillations.

The facility failed to ensure that walls, ceilings, and floors were kept clean and in good repair. Specific issues included water stains, mold-like staining, and dust accumulation on ceilings and air registers in several resident bathrooms, as well as torn floor mats and damaged door hardware in the back hall shower room.

The facility failed to ensure that walls, ceilings, and floors were kept clean and in good repair. Specific issues included water stains, mold/black stains, and damaged sheetrock in resident bathrooms, as well as torn floor mats, loose door knobs, and cracked baseboards in the back hall shower room. Additionally, exit doors were found with missing threshold seals and accumulated debris.

The facility failed to keep the bathroom floor shared by residents in rooms #43 and #44 and the electrical equipment in room #44 clean and in good repair. Specifically, the commode had poorly applied caulk, the floor around the commode was wet, and a tea-colored liquid oozed from the tile edges when stepped on.

The facility failed to protect food from contamination during breakfast service. Staff used used plates for seconds, touched the eating surfaces of plates with gloved thumbs, and used serving utensils that were returned to the food pan without changing gloves.

The facility failed to administer medications in accordance with physician orders, resulting in a 13% error rate. Specifically, a resident was not given calcium supplements with food as ordered, and errors were noted regarding the administration of medications for diabetes, blood pressure, and supplements.