Pennsylvania Department of Health
PINECREST MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PINECREST MANOR
Inspection Results For:

There are 91 surveys for this facility. Please select a date to view the survey results.

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PINECREST MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey completed on February 13, 2025, it was determined that Pinecrest Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store schedule II-V medications in a separately locked, permanently affixed compartment in three of four medication rooms reviewed (A/B, C/D and E/F); the facility failed to prevent the opportunity for potential unauthorized access of medications on two of four medication carts observed (D and F); and the facility failed to appropriately discard outdated medications for one of four medication carts reviewed (E wing).

Findings include:

Review of facility policy entitled "Narcotic Policy PCM" dated 2/06/25, revealed "Schedule II-V medications are stored in a permanently affixed, double-locked compartment separate from all other medications."

Review of facility policy entitled "Medication cart: Med Pass Guidelines" dated 2/06/25, revealed that "Multi-dose vials such as insulin must have either "opened on date" or "used by date" which should be checked prior to administration."

Review of facility policy entitled "Pharmaceutical Services and Medication Storage" dated 2/06/25, revealed "Medications will be in containers that meet regulatory requirements and stored safely. Except for those medications requiring refrigeration ...medications intended for internal use are stored in a medication cart ..."

Review of manufacturer's guidelines revealed that an open pen of Lantus Insulin (medication to treat diabetes and help control blood sugar levels) must be used within 28 days after opening or be discarded, even if the vial still contains insulin.

Observation of drug storage on 2/10/25, at 2:55 p.m. of C and D wings medication room refrigerator revealed a clear plastic locked box and inside the clear plastic box were two carpujects (a syringe device for the administration of injectable fluid medications) of Lorazepam (a controlled antianxiety medication). The shelf with the clear plastic box containing the Lorazepam was not permanently affixed to the refrigerator allowing the shelf and the Lorazepam to be removed from the refrigerator.

During an interview at the time of observation with Licensed Practical Nurse (LPN) Employee E6, he/she confirmed that the clear plastic box containing Lorazepam was not permanently affixed to the refrigerator. He/she also confirmed that the schedule II-V medications should be stored in a separately locked permanently affixed compartment.

Observation of drug storage on 2/10/25, at 3:12 p.m. of A and B wings medication room refrigerator revealed a clear plastic locked box and inside the clear plastic box was one carpuject and one vial of Lorazepam. The shelf with the clear plastic box containing the Lorazepam was not permanently affixed to the refrigerator allowing the shelf and the Lorazepam to be removed from the refrigerator.

During an interview at the time of observation with LPN Employee E7, he/she confirmed that the clear plastic box containing Lorazepam was not permanently affixed to the refrigerator. He/she also confirmed that the schedule II-V medications should be stored in a separately locked permanently affixed compartment.

Observation of drug storage on 2/10/25, at 3:16 p.m. of E and F wings medication room refrigerator revealed two carpujects of Lorazepam lying on the refrigerator shelf. The refrigerator lacked a separately locked permanently affixed compartment for the schedule II-V medications which allowed the Lorazepam to be removed from the refrigerator.

During an interview at the time of observation with LPN E5, he/she confirmed that the Lorazepam was not in a separately locked compartment that was permanently affixed to the refrigerator. He/she also confirmed that the schedule II-V medications should be stored in a separately locked permanently affixed compartment.

Observation of drug storage on 2/10/25, at 3:16 p.m. of E wing medication cart revealed an open pen of Lantus insulin with no date indicating when the pen was opened.

During an interview at the time of observation with LPN Employee E5, he/she confirmed that the open Lantus Insulin lacked an opened date. He/she also confirmed that due to the Lantus insulin having no opened date the insulin should have been discarded.

Observation of the D wing medication cart on 2/10/25, at 4:30 p.m. revealed that the medication cart was sitting in front of a resident's room with the back of the cart facing into the hallway. On the back of the medication cart were two open shelves with an open bottle of MiraLAX, an open bottle of Pepto-Bismol, and two bottles of Robitussin, one that had been opened. Further observations revealed that the nurse continued to two other resident rooms leaving the back of the cart facing into the hallway and out of view while in a resident's room.

During an interview at the time of observations with LPN Employee E4, he/she confirmed that there were medications on the shelf on the back of the medication cart which were out of view and could allowed unauthorized access to the medications. He/she also confirmed that the medications should not be accessible and should be locked in the medication cart.

Observation of the F wing medication cart on 2/10/25, at 4:50 p.m. revealed that the medication cart was sitting in front of a resident's room with the back of the cart facing into the hallway. On the back of the medication cart were two open shelves with an open bottle of MiraLAX, an open bottle of Milk of Magnesium, three bottles of Robitussin, two that were opened and two open bottles of Robitussin DM. Further observations revealed that the nurse continued to two other resident rooms leaving the back of the cart facing into the hallway and out of view while in a resident's room.

During an interview at the time of observations with LPN Employee E5, he/she confirmed that there were medications on the shelf on the back of the medication cart which were out of view and could allowed unauthorized access to the medications. He/she also confirmed that the medications should not be accessible and should be locked in the medication cart.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 04/10/2025

1. The refrigerators were fixed at the time of the survey. A medication box was installed and permanently affixed in the E/F wing medication refrigerator. The A/B and C/D wing medication boxes were permanently affixed to the refrigerator at the time of the survey so they were not able to be removed with the shelf.

The open Lantus insulin pen was discarded at the time of the survey.

The Miralax, milk of magnesium, and Robitussin were removed from the back of the medication cart.

2. An audit will be completed of all refrigerators to ensure that the refrigerators are in compliance with the medication boxes permanently affixed to the refrigerator and all Scheduled II-V medications.

An audit will be completed of all insulin vials and pens to ensure if they are opened there is a date on the pen or vial.

All medications were removed from the back of the medication carts.

3. All nursing employees will be reeducated on the following policies and procedures titled: Narcotic Policy PCM, Medication Cart: Med Pass Guidelines, and Pharmaceutical Services and Medication Storage.

4. An audit will be completed by the Quality Nurse or designee to ensure that the medication boxes are permanently affixed and Schedule II-V medications are stored in the box within the medication refrigerator. These audits will be completed monthly and then quarterly thereafter. An audit will be completed on insulin vials and pens to ensure if they are dated if opened and if expired discarded. An audit will be completed monthly and then quarterly thereafter. Audits on all medication carts to ensure that there are no medications on the back of the medication carts will will be completed weekly for one month, monthly for two months, and quarterly thereafter. These results will be reported quarterly to the Quality Assurance Performance Improvement Committee.

5. Corrective action date is April 10, 2024.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must 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. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to initiate a baseline care plan for one of 23 residents reviewed (Resident R99).

Findings include:

A facility policy entitled, "Care Plan: Baseline (IPOC)" dated 2/06/25, revealed "Baseline PCM IPOC will be entered and developed for each resident within 48 hours."

Resident R99 's clinical record revealed an admission date of 1/09/25, with diagnoses that included diabetes, high blood pressure, anemia, and acute kidney injury.

Resident R99 's clinical record lacked evidence that a baseline care plan was initiated for Resident R99.

During an interview on 2/12/25, at 1:00 p.m. the Nursing Home Administrator confirmed that the clinical record of Resident R99 lacked evidence that a baseline care plan was initiated.

28 Pa. Code 211.12(d)(1) Nursing services

Plan of Correction - To be completed: 04/10/2025

1. Resident R99's base line care plan was developed.

2. An audit will be completed on all admissions in the last 30 days to ensure a base line care plan was developed within 48 hours and provided to the resident and/or his/his representative. Any deficient practice will be corrected.

3. All licensed nursing employees will be reeducated on the facility policy titled "Care Plan: Baseline Interdisciplinary Plan of Care."

4. An audit will be completed by the Quality Director or designee on all new admissions to ensure that the baseline care plan is developed and implemented within 48 hours of admission and given to the resident and/or his/her representative. These audits will be completed weekly for one month, monthly for two months, and quarterly thereafter. These results will be reported quarterly to the Quality Assurance Performance Improvement Committee.

5. Corrective Action date will be April 10, 2025.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff:

§483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

Observations:

Based on reveiew of clinical records, observations and staff and resident interviews, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of seven of 23 residents interviewed (Residents R80, R12, R34, R37, R93, R79, and R51).

Findings include:

Independent interview on 2/10/25, at 4:13 p.m. revealed that Resident R51 disclosed that he/she cannot walk, uses an electric wheelchair for mobility, and requires a mechanical lift to transfer. Resident R51 shared that there are times (especially on off shifts and weekends) when he/she waits on the toilet for an hour to get help, and that he/she has waited so long to get to the bathroom, he/she soiled his/her clothing. Resident R51 also stated that staff will come in and turn off the bell, and not return.

Interviews during the Resident Council meeting on 2/11/25, between 1:00 p.m. and 2:15 p.m. revealed that six out of six alert and oriented residents were in attendance (Residents R80, R12, R34, R37, R93, and R79) and reported concerns related to staff not responding to their call bells timely, and all six residents confirmed that it is common to wait over an hour for your call bell to get answered, especially on 3-11 shift and weekends, and that they "have just learned to do what they can for themselves and let other stuff go because you can't get help anyways."

Resident R12 shared that he/she waited this morning until 10:30 a.m. to get his/her shower and then decided he/she would have to go ahead and get dressed before lunch so he/she could attend the meeting at 1:00 p.m. Resident R12 also stated that he/she has not been walked by staff and that his/her walker hasn't been out of the closet in months.

Resident R34 shared that he/she "can't remember last shower I got, and that he/she washes up at the sink." Resident R34 also stated that he/she sleeps in a recliner because he/she knows they can get out of it on his/her own to get to the bathroom when needed.

Resident R79 shared that he/she is "independent" in his/her room and can transfer from surface to surface on his/her own, but that he/she observes and witnesses long call bell waits.

Resident R93 confirmed "you just know that if they are short-staffed you aren't going to get help anytime fast, and especially on evenings and weekends, you just don't ring because no one's going to answer it."

Resident R80 shared that he/she is supposed to be walked Monday, Wednesday, and Friday and if there are not enough nurse aides, the restorative aides (RA) get pulled to work the floor, and he/she hasn't been walked in a couple of weeks. Review of Resident R80's clinical record revealed a physician's order dated 7/17/24, for walking three times a week, and review of the Restorative Detail Report revealed that he/she hadn't been walked since 1/31/25.

During an interview on 2/12/25, at 9:45 a.m. Licensed Practical Nurse Employee E8 confirmed Resident R80 had not been walked since 1/31/25, due to restorative staff being pulled to the floor to work as nurse aides, and that today there are two restorative staff on the floor as nurse aides until 11:00 a.m. and then will switch to performing restorative duties.

Observation on 2/13/25, at 8:47 a.m. revealed RA Employee E3 was providing feeding assistance to a dependent resident. During an interview at that time, RA Employee E3 verified that they are pulled to the floor to work as nurse aides due to nursing being short staffed and that often only leaves time during the day for restorative duties with about three residents from 1:30 p.m. to 3:00 p.m. and working around other afternoon activities for the residents.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.12(d)(4)(5) Nursing services

Plan of Correction - To be completed: 04/10/2025

1. Resident R80's restorative nursing care orders for ambulation were resumed. An announcement will be made at resident council to state that we were made aware that there are concerns with call bell response time, showers being completed that are related to staffing concerns. This plan of correction will be shared with the residents at resident council.

Resident R12's concern regarding lack of assistance with walker use has been reviewed. The assigned staff have been re-educated on the resident's mobility needs, and restorative nursing aides are now ensuring assistance is provided per the care plan. Follow-up checks will be conducted weekly for four weeks to ensure continued compliance.

Residents R12 and R34, who reported missed showers, will be interviewed, and their care plans have been reviewed to prevent recurrence. Assigned CNAs have been counseled on adherence to shower schedules, and their performance is being monitored.

2. An audit will be completed by the Director of Nursing or her designee and the Registered Nurse Assessment Coordinator or her designee on all residents with restorative nursing orders to see if they are still appropriate and if their orders are being fulfilled.

An initial audit will be conducted by the Director of Nursing or her designee to see if showers are being completed. This audit will be conducted on 35% of the resident census. A revision of the current shower schedule will be revised if the audits result ongoing issues with shower completion.

3. The restorative nursing program at Pinecrest Manor will be restructured where the current restorative nursing aides and coordinator will be training other staff members to be certified in restorative nursing to ensure that orders are fulfilled.

All nursing employees will be reeducated by the Director of Nursing, Administrator or their designees on shower schedules, the importance of toileting, rounding and ambulation, shower schedules and documentation requirements, and call bell expectations and timeliness.

4. Audits will be completed by the Restorative Coordinator or her designee on all residents with restorative nursing orders to ensure that orders are completed and that their physical and mental needs are met. These audits will be completed by the Restorative Coordinator or designee weekly for 4 weeks and monthly thereafter. These results will be reported at the Quarterly Quality Assurance Meeting.

Rounds will be completed by the Director of Nursing, Administrator or her designee to ensure that call bells are being answered in a timely manner. During these rounds a resident will be interviewed to discuss any concerns. These rounds will occur every other week where 5 residents will be interviewed to make sure their needs are met.

Audits on showers being completed will be completed by the Director of Nursing or her designee on 15 residents per week for 4 weeks and then monthly thereafter. These results will be reported at the Quarterly Quality Assurance Committee Meeting.
The Director of Nursing and Administrator will oversee implementation and review findings to determine if additional corrective actions are necessary.

5. Corrective action date will be April 10, 2025.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must 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.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observations, review of clinical records and facility policy, and staff interview, it was determined that the facility failed to prevent the potential for cross contamination (the spreading of germs/microorganisms from one surface to another) during wound care for one of 23 residents reviewed (Resident R13).

Findings include:

A facility policy entitled, "Handwashing and Hand Hygiene" dated 2/06/25, revealed that hand hygiene be performed after handling soiled equipment and after removing gloves.

Resident R13's clinical record revealed an admission date of 3/15/22, with diagnoses that included Alzheimer's Disease (brain condition that causes a progressive decline in memory, thinking, learning and organizing skills), Venous stasis (a condition that occurs when blood doesn't flow properly from the legs back to the heart), and congestive heart failure (CHF- long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply).

Observation of wound care on 2/12/25, at 9:27 a.m. revealed the following:

Licensed Practical Nurse (LPN) Employee E1 donned (put on) a clean gown and gloves, positioned Resident R13's left leg, removed the sock, changed gloves, removed the soiled dressing, changed gloves, cleansed the wound, changed gloves, applied the medication to the wound, changed gloves, and applied the clean dressing. LPN Employee E1 failed to perform hand hygiene each time he/she changed his/her gloves, or four times throughout the dressing change.

Registered Nurse (RN) Employee E2 donned a clean gown and gloves, assisted with positioning Resident R13's left leg, removed gloves, used bare hands to pick up and move garbage can next to end of bed, donned gloves, picked up and held Resident R13's left foot at the ball of the foot and near the Achille's, and using his/her gloved finger pointed to areas on wound near the open surface of the wound during the dressing change. RN Employee E2 failed to perform hand hygiene after touching the garbage can before donning clean gloves.

During an interview at that time RN Employee E2 and LPN Employee E1 confirmed that they should have performed hand hygiene before donning clean gloves.

28 Pa. Code 211.10(c)(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/10/2025

1. Resident R13 will be examined by the physician's assistant to ensure there were no negative outcomes. Employee E1 and Employee E2 have completed reeducation by the Quality Registered Nurse on proper hand hygiene practices specifically related to wound care and the need for hand hygiene after touching potentially contaminated items.

2. Random audits will be conducted by the Quality Registered Nurse on all residents receiving wound dressing changes over a two-week period to ensure proper procedures are being followed, including handwashing and that the employees perform hand hygiene after touching potentially contaminated items.

3. All nurses, including Licensed Practical Nurses and Registered Nurses, will undergo reeducation by the Director of Nursing or her designee on the "Handwashing and Hand Hygiene" policy as it applies to wound care and the need for hand hygiene after touching potentially contaminated items. This education will be incorporated into new employee orientation under infection control procedures for new nurses being onboarded.

4. A weekly audit on 25% of the wound care dressing changes on all shifts and hand hygiene practices will be performed by the Quality Nurse or their designee for a four-week period, followed by monthly audits thereafter. The results will be presented at the quarterly Quality Assurance Performance Improvement (QAPI) Committee.

5. The corrective action plan will be fully implemented by April 10, 2025.

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