Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pinecrest Medical Care Facility during CMS and state inspections, most recent first.
The facility failed to implement an effective infection prevention and control program, with deficiencies in documenting infection symptoms, conducting departmental surveillance, and handling medications. An LPN mishandled medications by using bare hands and not using barriers for insulin pens. A resident's catheter tubing and drainage bag were observed on the floor, contrary to facility policy.
The facility failed to update care plans for several residents, leading to potential inadequate care. Residents with infections, such as UTIs, did not have care plans reflecting necessary interventions for their symptoms. Additionally, a resident who required a change in transfer method after a leg injury did not have their care plan updated promptly. The facility's policy mandates care plan revisions upon status changes, which was not followed.
The facility failed to provide adequate staffing, leading to unsupervised residents in the dementia unit. Residents reported poor CNA attitudes and delayed assistance, resulting in accidents. Observations showed residents wandering without supervision, and staffing schedules confirmed consistent understaffing. The DON acknowledged safety concerns due to insufficient staff, especially in the SCU, where residents required increased supervision.
The facility failed to secure narcotic medications properly and did not date biologicals on a medication cart. Lorazepam, a Schedule II controlled substance, was found in a refrigerator without a secondary lock, contrary to policy. An LPN was observed mishandling medications during a pass, dropping tablets and using bare hands without hygiene practices, which compromised medication safety.
A resident's advance directive, which included a DNR order, was not honored by the facility. The resident's AD specified conditions under which life-sustaining treatment should be withheld, but these conditions were not met. Despite this, a Patient Advocate signed a DNR consent form without the authority to change the resident's code status. The Social Services Coordinator confirmed the resident's competence at the time of signing the AD and acknowledged the PA's lack of authority.
The facility failed to report potential abuse incidents involving two residents with severe cognitive impairment. One resident was found with multiple bruises on different occasions, and another had a bruise and a Band-Aid on her arm, with no known cause. The incidents were not reported to the State Agency, and the facility's policy on abuse investigation was not followed. The ADON and NHA admitted to issues with the incident reporting process.
The facility failed to investigate potential abuse for two residents with severe cognitive impairment. One resident was found with bruises on her thigh and arm, but the facility did not conduct a full investigation or interview all relevant staff. Another resident had bruises on her legs, possibly from wheelchair foot pedals, but no investigation was conducted. The facility did not follow its policy on investigating and reporting potential abuse.
The facility failed to provide written transfer notification to a resident and their representative, including the reason, effective dates, and the location of transfer. The medical record did not indicate that a written notification was given or sent. An administrative staff member was unaware of the requirement to send such notifications. The facility's policy specifies that a notice of transfer and the bed hold policy should be provided.
The facility failed to develop comprehensive care plans for two residents, leading to unmet needs. One resident, with significant weight loss and a request for palliative care, lacked a documented care plan. Another resident, exhibiting severe cognitive impairment and wandering behavior, had no care plan addressing these issues. Staff confirmed the absence of appropriate care plans, highlighting the facility's failure to adhere to its policies.
A resident with a PICC line for vancomycin administration experienced deficiencies in care when two LPNs failed to check for blood return before administering saline, contrary to facility policy. Additionally, the PICC line dressing was overdue for a change. Interviews revealed a lack of training and awareness among the LPNs regarding these procedures.
Two residents in an LTC facility did not receive their prescribed diets and hydration needs were unmet, leading to significant weight loss and dehydration risk. One resident with dysphasia did not receive a pureed banana as ordered, and another resident's meal did not match the physician's order, with fluids placed out of reach. Staff were unclear on diet specifications, and the facility lacked a defined diet plan, contributing to these deficiencies.
The facility failed to ensure that three contracted CNAs completed required dementia training and demonstrated necessary skills. The CNAs were evaluated using self-assessment checklists without further evaluation by the facility. Interviews revealed that the facility's process for evaluating new hires was incomplete, and the responsible staff member was no longer employed. The facility's CNA Competency forms showed incomplete evaluations in critical areas, and the ADON acknowledged that the self-evaluations did not demonstrate observed competency.
The facility failed to maintain a medication error rate below five percent, resulting in a 10.00 percent error rate. Errors included incorrect dosages of torsemide and insulin for a resident, improper administration of calcium carbonate, and delayed antibiotic administration for another resident. The facility's procedures, such as using stickers for medication changes, were not followed, contributing to these errors.
The facility failed to provide adaptive dining equipment for two residents, leading to difficulties in food consumption and independent eating. A resident who is legally blind did not receive colored plates and Styrofoam cups as required, while another resident with dysphagia did not receive straws for thickened liquids, despite care plan instructions.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by several deficiencies. The Infection Preventionist (IP) did not document signs and symptoms of infections for residents on the infection surveillance line list for May 2024, leaving the symptoms column blank for 13 residents. Additionally, the IP admitted that departmental surveillance for infection control practices was not conducted for May, June, and July 2024, except for a single form from the dietary department. The facility's policy required surveillance activities to be monitored facility-wide, but this was not adhered to. During medication administration, an LPN was observed mishandling medications by dropping tablets on the medication cart and using bare hands to place a dropped spironolactone tablet into a medication cup without performing hand hygiene. Furthermore, the LPN did not use a barrier when placing an insulin pen on a resident's bedside table and failed to clean the pen before returning it to the medication cart. The Assistant Director of Nursing confirmed that barriers are required when medical items are placed on bedside tables, as per facility policy. A resident with an indwelling urinary catheter was observed multiple times with catheter tubing and drainage bag resting on the floor, contrary to the facility's catheter care policy. The policy stated that catheter drainage bags should be covered and kept off the floor to maintain dignity and privacy. The resident's electronic medical record indicated a physician order for an ongoing indwelling urinary catheter due to dysuria. Both the LPN and RN acknowledged that the catheter tubing and drainage bag should not be on the floor, indicating a lapse in adherence to the facility's catheter care policy.
Failure to Update Care Plans for Residents with Infections and Transfer Needs
Penalty
Summary
The facility failed to revise or update care plans to reflect the current status of five residents, leading to potential inadequate care and unmet needs. Specifically, the care plans for residents diagnosed with infections, such as urinary tract infections (UTIs), were not updated to include necessary interventions. For instance, Resident #50 was diagnosed with a UTI and prescribed antibiotics, but their care plan did not address the symptoms of increased fatigue and hematuria. Similarly, Resident #39, who also had a UTI, did not have a care plan that included interventions for symptoms like urinary urgency and mental changes. Resident #20's care plan was missing interventions for painful urination and mental status changes associated with their UTI. Resident #32, who had a multi-drug resistant organism infection and a UTI, lacked a care plan addressing these infections and the maintenance of their PICC line. Additionally, Resident #29 experienced a change in transfer needs following an incident where they hurt their leg during a transfer. Despite being transferred to the hospital and returning with a leg immobilizer, the care plan was not updated to reflect the change from a sit-to-stand lift to a maxi lift until much later. The Assistant Director of Nursing acknowledged that the care plan should have been updated immediately upon the resident's return from the hospital. The facility's policy requires care plan revisions upon a resident's status change, but this was not adhered to in these cases.
Inadequate Staffing in Dementia Unit
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by observations, interviews, and record reviews. During a confidential group meeting with ten residents, all participants expressed concerns about inadequate staffing. Residents reported that Certified Nurse Aides (CNAs) displayed poor attitudes, ignored call lights, and failed to provide timely assistance, leading to accidents and prolonged periods of sitting in soiled conditions. The Resident Council minutes from previous meetings also highlighted ongoing issues with call light response times and a lack of resolution or action taken by the facility. Observations on the Special Care Unit (SCU), a locked dementia/behavioral care unit, revealed multiple instances of residents wandering unsupervised and appearing lost or confused. On several occasions, residents were observed attempting to enter locked rooms or assist each other without staff intervention. The lack of staff presence in critical areas such as hallways and nurses' stations was noted, with staff only appearing intermittently to redirect residents. Interviews with CNAs confirmed that staffing was often insufficient, with only one or two CNAs scheduled to work the SCU, and a nurse only present during medication pass. A review of the facility's staffing schedules and shift summaries from June to July 2024 showed consistent understaffing across various shifts, with the number of scheduled staff falling short of the assessed need based on resident census and acuity. The Director of Nursing acknowledged the safety concerns associated with inadequate staffing, particularly on the SCU, where residents required increased supervision due to cognitive impairments and behavioral issues. The facility's assessment indicated a need for a more structured environment with less stimulation for these residents, yet the staffing levels did not meet these requirements.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage and handling of medications, specifically narcotics and biologicals, as observed during a survey. In one of the medication rooms, two vials and one liquid dropper bottle of lorazepam, a Schedule II controlled substance, were found in a refrigerator without a secondary lock, which is against the facility's policy requiring double locks for such medications. This was confirmed by an LPN and acknowledged by the Assistant Director of Nursing, who had previously requested a lock for the refrigerator. Additionally, the survey revealed that two opened insulin pens on a medication cart were undated, which is a violation of proper medication storage protocols. Furthermore, during a medication pass for a resident, an LPN was observed dropping multiple tablets on the medication cart and improperly handling them. The LPN dropped a tablet of carvedilol and a doxycycline, discarding them in the trash, but when a spironolactone tablet was dropped twice, the LPN picked it up with bare hands and placed it in the medication cup for the resident without performing hand hygiene. This incident highlights a failure in maintaining proper medication handling and hygiene practices, as the LPN did not provide an explanation for these actions.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to honor the advance directive of a resident, identified as R20, who had a documented Do Not Resuscitate (DNR) order and an advance directive (AD) signed in 2014. The AD specified that R20 wanted life-sustaining treatment unless in a coma or vegetative state, which was not the case according to a recent Minimum Data Set (MDS) assessment and physician documentation. Despite this, a Patient Advocate (PA) signed a DNR consent form in 2024, which was not supported by the AD, as R20 had not granted the PA the authority to change the code status. The Social Services Coordinator, responsible for overseeing advance directives, confirmed that R20 was competent when the AD was signed and acknowledged that the PA did not have the legal authority to alter R20's code status. There were no additional documents indicating that R20 had amended or rescinded the original AD. The facility's policy on residents' rights and advance directives was reviewed, which supports a resident's right to request medical treatment and formulate an advance directive, but the facility failed to adhere to this policy in R20's case.
Failure to Report Potential Abuse Incidents
Penalty
Summary
The facility failed to report potential abuse to the State Agency as required for two residents, R23 and R45, who were reviewed for abuse reporting. Resident R45, who had severe cognitive impairment due to dementia and anxiety, was observed with a bruise on her right thigh. The facility's incident and accident reports documented multiple bruises on different occasions, but these incidents were not reported to the State Agency. The Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA) admitted that the incidents were not reported due to a lack of awareness and issues with the incident reporting process. Resident R23, also with severe cognitive impairment due to Alzheimer's dementia, was found with a bruise and a Band-Aid on her upper left arm. The facility's records showed that the cause of the bruising and the application of the Band-Aid were unknown, and no abuse investigation was initiated. The ADON confirmed that the incident was not reported to the State Agency, and the Director of Nursing (DON) noted that someone must have known what happened, as R23 did not have access to Band-Aids and lacked the cognitive ability to apply one. The facility's policy on abuse, neglect, and exploitation requires the identification and investigation of potential abuse indicators, such as bruises. However, the policy was not followed in these cases, as the incidents involving R23 and R45 were not reported to the State Agency, and the investigations were not conducted thoroughly. The ADON acknowledged that the floor nurses were not always aware of what incidents were reportable, leading to a failure in the reporting process.
Failure to Investigate Potential Abuse in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to investigate potential abuse as required for two residents, leading to a deficiency. Resident #45, who has severe cognitive impairment due to dementia and anxiety, was observed with bruises on multiple occasions. On one occasion, a bruise was noted on her right thigh, and on another, bruises were found on her left arm. The facility's incident and accident reports did not include interviews with all staff who might have been involved or witnessed the incidents, and the Assistant Director of Nursing and Nursing Home Administrator admitted that the incidents were not fully investigated. Resident #23, also with severe cognitive impairment, was found with bruises on her lower legs. The bruises were noted during a shower, and it was suggested they might have been caused by the foot pedals of her wheelchair. However, no investigation was conducted to determine the cause of the bruises, and a written statement from the CNA who discovered the bruises was not obtained until much later. The Director of Nursing acknowledged that an investigation should have been conducted to rule out abuse or mistreatment. The facility's policy on abuse, neglect, and exploitation requires a thorough investigation of alleged incidents, including interviewing all involved persons and documenting the investigation. However, in both cases, the facility did not adhere to its policy, resulting in a failure to properly investigate and report potential abuse or neglect to the State Agency.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide written transfer notification to a resident and the resident's representative, including the reason, effective dates, and the location to which the resident was being transferred. This deficiency was identified for one resident who was transferred to the hospital. The medical record for this resident did not indicate that a written notification of transfer was given to the resident or sent to her representative. During an interview, an administrative staff member stated that she did not send written notifications of hospitalization stays to any residents or their representatives and was unaware that this was required. The facility's policy on transfers and discharges, dated July 2024, specifies that a notice of transfer and the facility's bed hold policy should be provided to the resident and representative as indicated.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, resulting in deficiencies in addressing their specific needs. Resident #54 was admitted with multiple diagnoses, including acute and chronic respiratory failure, congestive heart failure, and dementia. Despite significant weight loss over several months and the family's request for palliative care, there was no physician order or care plan for palliative care documented in the electronic medical record. The facility's policy required evaluation for end-of-life care concerns and coordination of a care plan, which was not implemented for this resident. Resident #41, diagnosed with dementia and anxiety disorder, exhibited severe cognitive impairment and wandering behavior. Observations revealed the resident's exit-seeking behavior and difficulty in redirection, especially during attempts to reduce psychotropic medications. Despite these behaviors, the resident's care plan lacked focus areas, goals, or interventions related to wandering, exit-seeking behavior, or elopement risk. The facility's policy mandated comprehensive care plans to describe services for maintaining the resident's well-being, which was not adhered to in this case. Interviews with facility staff confirmed the absence of appropriate care plans for both residents. The Assistant Director of Nursing acknowledged the need for a palliative care plan for Resident #54, while the Director of Nursing confirmed that Resident #41 required increased supervision due to unsafe wandering. These deficiencies highlight the facility's failure to implement care plans that address the residents' specific needs and conditions, as required by their policies.
Deficiency in PICC Line Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for a resident with a peripherally inserted central catheter (PICC) line. The resident had a physician's order for vancomycin to be administered intravenously for sepsis. During observations, it was noted that two Licensed Practical Nurses (LPNs) did not check for blood return before administering saline solution into the PICC line, which is a necessary step to confirm catheter functionality and prevent complications. Additionally, the PICC line dressing was overdue for a change, as the last recorded change was on a date earlier than required by the physician's order. Interviews with the LPNs revealed a lack of awareness and training regarding the necessity of checking for blood return and the responsibility for changing the PICC line dressing. The facility's policy mandates that PICC lines be flushed and aspirated for blood return prior to each infusion. However, the skills checklist for the LPNs did not include current competencies for intravenous skills related to administration and maintenance, indicating a gap in training and adherence to the facility's policy.
Nutritional and Hydration Deficiencies in Resident Care
Penalty
Summary
The facility failed to meet the nutritional needs and preferences of two residents, resulting in deficiencies in their care. Resident #29, who has a history of dysphasia, dementia, and other medical conditions, was not provided with the prescribed diet as per the physician's order. The dietary staff did not include a pureed banana in the resident's meal, despite it being part of the physician's order and indicated on the meal tray card. The dietary aide admitted to not providing the banana due to difficulty in achieving the right consistency, and the certified dietary manager confirmed that the resident should have received it. Additionally, yogurt, which was part of the resident's preferences, was not initially provided until requested by the surveyor. Resident #54, with diagnoses including respiratory failure, heart failure, and dementia, experienced significant weight loss over several months, indicating a failure to meet nutritional needs. The resident's lunch tray did not match the physician's order, as the salisbury steak was not ground to the specified consistency. The dietary aides were unsure of the diet specifications, and the facility did not have a defined diet called HF/HC, which was indicated on the tray card. Furthermore, the resident's fluids were placed out of reach, leading to dehydration risk, as the resident was observed crying out for water multiple times without adequate assistance. The facility's failure to provide the prescribed diets and ensure accessible hydration for these residents highlights deficiencies in dietary management and staff training. The care plans for both residents included specific dietary and hydration interventions that were not followed, contributing to the risk of physical decline and dehydration. The facility's policy on hydration was not adhered to, as beverages were not consistently made available and within reach for the residents.
Inadequate Competency Evaluation for Contracted CNAs
Penalty
Summary
The facility failed to ensure that three contracted Certified Nurse Assistants (CNAs) completed the required dementia training and demonstrated the necessary skills and techniques to care for residents. The CNAs, identified as F, AA, and BB, were evaluated using a self-assessment checklist provided by their contract company, which did not include any further evaluation of their skills by the facility. The self-evaluations indicated how frequently the CNAs performed tasks and their self-perceived proficiency, but there was no evidence of observed competency or completion of mandatory dementia training. During interviews, it was revealed that the facility's process for evaluating new hires involved a checklist completed during a two-day orientation, with the responsibility for determining competency resting on the CNA staff assigned to orientation. However, the Unit Manager, RN E, confirmed that the CNAs were no longer on orientation and were providing care throughout the facility. The responsible staff member for completing the evaluations was no longer employed, and RN E was unable to confirm if the CNAs were deemed competent before performing resident care activities. Further review of the facility's CNA Competency forms for CNAs F, AA, and BB showed incomplete evaluations in several critical areas, such as assisting residents at meals, catheter care, and personal hygiene tasks. The Assistant Director of Nursing (ADON) acknowledged that evaluations should be complete before CNAs provide care and that the self-evaluations from the contract company did not demonstrate observed competency. The facility's assessment indicated that they offer services based on resident needs, including care for those with cognitive impairments, but the lack of complete competency checks for the CNAs suggests a failure to meet these standards.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than five percent, resulting in a 10.00 percent error rate. This was observed during medication administration for two residents. For one resident, an LPN dispensed an incorrect dosage of torsemide due to a recent order change that was not followed, administering one 20 mg tablet instead of the prescribed two 20 mg tablets. Additionally, the same resident received an incorrect insulin dosage when the LPN failed to prime the insulin pen correctly, resulting in the administration of 11 units instead of the prescribed 12 units. Furthermore, the resident was given calcium carbonate along with other medications in one cup, contrary to the requirement that it be taken separately. Another resident experienced a delay in antibiotic administration, as the LPN was over an hour late in administering vancomycin intravenously. The LPN also failed to check for blood return before administering saline solution into the resident's PICC line. These errors were identified during observations and interviews, with the Assistant Director of Nursing acknowledging the issues and noting that the facility had procedures, such as using stickers for medication changes, which were not followed. The facility's policy on medication administration emphasizes adherence to physician orders and professional standards to prevent such errors.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment for two residents, resulting in increased difficulty with food consumption and independent eating. Resident #22, who is legally blind, was observed during lunch meals on two separate occasions without the required colored plates and Styrofoam cups as indicated in her care plan. The care plan specified the use of colored plates to assist with her visual impairment and Styrofoam cups due to difficulty holding regular cups. Despite these instructions, R22 was served meals on a white plate and with a regular mug, contrary to her documented needs. Resident #29, with a history of dysphagia, stroke, and other medical conditions, was observed during breakfast meals without the necessary straws for her thickened liquids, as indicated in her care plan and meal tray card. The care plan and tray card instructed the use of straws for beverages, but staff members expressed confusion and did not provide straws, citing difficulty for the resident in using them with thickened liquids. This inconsistency between the care plan and staff actions led to the resident not receiving the appropriate adaptive equipment for her dietary needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Powers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roubal Care And Rehabilitation Center | 19.7 mi | ★★★★★ | 0 | 0 |
| Bishop Noa Home For Senior Citizens | 21.3 mi | ★★★★★ | 11 | 0 |
| Christian Park Village | 21.4 mi | ★★★★★ | 2 | 0 |
| Christian Park Health Care Center | 21.6 mi | ★★★★★ | 5 | 0 |
| Maryhill Manor | 24.1 mi | ★★★★★ | 7 | 0 |
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