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 84 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 March 14, 2024, 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:

483.21(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 interviews, it was determined that the facility failed to initiate a baseline care plan for one of 22 residents reviewed (Resident R201) and failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 22 residents reviewed (Resident R99).

Findings include:

A facility policy entitled, "Care Plan: Baseline (IPOC)" dated 2/21/24, stated "Baseline PCM IPOC will be entered and developed for each resident within 48 hours."

Resident R201 's clinical record revealed an admission date of 2/27/24, with diagnoses that included diabetes, high blood pressure, and peripheral arterial disease (narrowing of arteries, usually in the leg that result in reduced blood flow).

Resident R201 's clinical record lacked evidence that a baseline care plan was initiated for Resident R201.

During an interview on 3/13/24, at 1:23 p.m. the Nursing Home Administrator confirmed that the clinical record of Resident R201 lacked evidence that a baseline care plan was initiated.

Resident R99's clinical record revealed an admission date of 1/24/24, with diagnoses that included history of a stroke (damage to the brain from interruption of its blood supply), cardiovascular disease (disease of the heart or blood vessels), history of falling, and anxiety.

Resident R99's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R99 and/or his/her representative.

During an interview on 3/14/24, at 12:05 p.m. the Director of Nursing confirmed that the clinical record of Resident R99 lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative.

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

Plan of Correction - To be completed: 05/10/2024

1. Resident R201 base line care was developed. For Resident R99 is now deceased so the facility is unable to give the baseline care plan to the resident and or her representative.

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 May 10, 2024

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to develop a comprehensive care plan for one of 22 residents reviewed (Resident R7).

Findings include:

Review of facility policy entitled "Care Plan: Interdisciplinary" dated 2/21/24, stated the purpose is to "Provide a comprehensive care plan that includes measurable objectives and timetables to meet medical, nursing, mental, and psychosocial needs that are identified including those identified in the comprehensive assessment, and formulate individualized treatment plans that promote maximum functioning and well-being" and "Nursing staff must notify RNAC (Registered Nurse Assessment Coordinator) of changes that could initiate new or additional care plans."

Resident R7's clinical record revealed an admission date of 3/15/21, with diagnoses that included Alzheimer's Dementia (a group of symptoms affecting memory, thinking, and social abilities), Seizures, and High Blood Pressure.

Resident R7's clinical record revealed a physician's order dated 5/30/23 indicating "Wanderguard (a bracelet applied to a resident's wrist or ankle or a device used by the resident for mobility [walker or wheelchair]to alert the staff of residents attempts to leave the facility) to prevent resident from leaving the facility unattended."

The clinical record lacked evidence that a care plan had been developed to address Resident R7's risk for wandering or elopement and use of wanderguard bracelet.

During an interview on 3/13/24, at approximately 3:37 p.m. the Nursing Home Administrator and Director of Nursing confirmed that a care plan had not been developed to address Resident R7's wandering or elopement risk and use of a wanderguard bracelet.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(3)(5) Nursing services

Plan of Correction - To be completed: 05/10/2024

1. Resident R7 care plan was updated to include a wanderguard at the time of the survey.

2. The facility will complete an audit of all resident's that have a wanderguard's ordered to make sure they are also care planned.

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

4. Audits will be completed by the Quality Nurse or designee on all resident care plans that have wanderguards ordered. 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 May 10, 2024

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

§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 policy and manufacturer's instructions, observation, and staff interview, it was determined that the facility failed to ensure that medications were properly dated when opened and discarded in a timely manner for one of two medication rooms observed (Unit A/B medication room).

Findings include:

Review of facility policy entitled "PPD [solution used for tuberculosis testing upon admission and for employment], Administration" dated 2/21/24, revealed "Discard bottle 30 days after opened."

Review of manufacturer's recommendations for Tubersol PPD indicated that vials which are entered and in use for 30 days should be discarded.

Observation of drug storage on 3/13/24, at approximately 11:12 a.m. in Unit A/B medication storage room refrigerator revealed and an opened vial of Tubersol PPD without an open date, therefore the staff were unable to determine the discard date.

During an interview at that time, Licensed Practical Nurse Employee E2 confirmed that the opened Tubersol PPD vial lacked an open date and staff were unable to determine the discard date.

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: 05/10/2024

1. The open TB vial without a date was discarded at the time of the survey.

2. An audit will be completed of all refrigerators to ensure that open TB vials are dated. Any open TB vials found without a date will be discarded.

3. All nursing employees will be reeducated on the policy titled "PPD Administration" and dating any TB open vials.

4. An audit will be completed by the Quality Nurse or designee to ensure that open TB vials are dated. 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 May 10, 2024.

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