Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Manor during CMS and state inspections, most recent first.
Inaccurate MDS Coding for Falls, Weight Loss, Alarms, Insulin, and Anticoagulant Use: The facility failed to ensure MDS assessments accurately reflected resident status for several residents. One resident’s fall was not coded despite being found on the floor and later hospitalized with a fractured femur; another resident’s significant wt loss was coded incorrectly; a resident with a chair alarm had alarm use coded as not used; insulin-related MDS items were coded for a resident who had no insulin orders or administration; and anticoagulant use was coded as no despite a resident receiving apixaban during the lookback period.
A resident with diabetes, A-Fib, and schizoaffective disorder had an order for scheduled Novolog with sliding scale coverage, and the MDS showed insulin injections during the look-back period. However, the clinical record had no evidence of a care plan addressing insulin use, and the RNAC confirmed that no such care plan had been developed.
Opened inhalers on a medication cart lacked required open dates. Surveyors observed one Trelegy Ellipta Diskus and one Fluticasone Salmeterol Diskus in use on the C Hall medication cart without open dates, and an LPN confirmed both were opened and missing dates. Facility policy and manufacturer instructions required these medications to be dated after opening and discarded within the specified timeframes.
The facility failed to properly store Schedule II-V medications in locked, permanently affixed compartments in three medication rooms, and did not prevent unauthorized access to medications on two medication carts. Additionally, an open pen of Lantus insulin lacked an 'opened on' date, leading to improper medication management. LPNs confirmed these deficiencies during interviews.
Pinecrest Manor failed to develop a baseline care plan for a resident within 48 hours of admission, as required by federal regulations. The resident, who had multiple diagnoses including diabetes and acute kidney injury, did not have a baseline care plan documented in their clinical record. This deficiency was confirmed by the Nursing Home Administrator during an interview.
The facility failed to provide sufficient nursing staff, resulting in delayed care for residents. A resident reported waiting an hour for assistance on the toilet, while others noted long call bell wait times, especially during off shifts. Residents have adapted by managing their own needs due to staff shortages. Restorative aides are often reassigned to cover nursing duties, impacting their ability to perform restorative care.
A facility failed to prevent cross-contamination during wound care for a resident with Alzheimer's, venous stasis, and CHF. An LPN changed gloves multiple times without performing hand hygiene, and an RN handled a garbage can without washing hands before continuing care. Both staff members acknowledged the lapse in hand hygiene.
The facility did not meet the required NA staffing ratios for the evening and overnight shifts. On a specific day, with a census of 101 residents, the evening shift had 8.05 NAs instead of the required 9.18, and the overnight shift had 6.37 NAs instead of the required 6.73. This was confirmed by the Nursing Home Administrator.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day, providing only 2.94 hours on a specific day. This deficiency was confirmed by the Nursing Home Administrator during an interview.
The facility failed to initiate a baseline care plan for a resident with diabetes, high blood pressure, and peripheral arterial disease within 48 hours of admission. Additionally, another resident with a history of stroke, cardiovascular disease, history of falling, and anxiety did not receive a written summary of the baseline care plan and order summary.
The facility failed to develop a comprehensive care plan for a resident with Alzheimer's Dementia, Seizures, and High Blood Pressure. Despite a physician's order for a Wanderguard bracelet to prevent elopement, the clinical record lacked a care plan addressing the resident's risk for wandering or elopement. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner. An opened vial of Tubersol PPD in the Unit A/B medication storage room lacked an open date, making it impossible for staff to determine the discard date. This was confirmed by an LPN during an interview.
Inaccurate MDS Coding for Falls, Weight Loss, Alarms, Insulin, and Anticoagulant Use
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected resident status for five residents. The report cites inaccurate coding in MDS sections related to falls, weight loss, alarms, insulin use, and anticoagulant use. The cited regulatory requirements included 28 Pa. Code 201.14(a) and 28 Pa. Code 211.5(f)(ix). Resident R94 had an admission diagnosis that included a displaced intertrochanteric femur fracture, high blood pressure, and a history of falling. His/her discharge MDS with an ARD of 12/19/25 coded the falls item as no, yet the clinical record documented that on 12/19/25 the resident was found on the floor complaining of left hip and groin pain and was sent to the ER. The next day, the resident was admitted with a fractured femur under the hardware from a previous fracture. The RNAC confirmed the MDS was coded inaccurately regarding falls. Resident R30 had diagnoses including cerebral palsy, anorexia nervosa, and depression, and the record showed significant weight loss over the prior six months, including a drop from 76.1 lbs to 62.4 lbs, from 73.9 lbs to 62.4 lbs, and from 77.8 lbs to 62.4 lbs. The quarterly MDS with an ARD of 9/1/25 coded weight loss as no or unknown. Resident R105 had Parkinson’s disease, high blood pressure, and repeated falls, and had a physician order for a chair/bed pull alarm with checks every shift. Although observations showed a chair alarm attached while the resident sat in a wheelchair and the TAR documented alarm checks since the order, the admission MDS with an ARD of 12/9/25 coded bed and chair alarms as not used. The RNAC confirmed the alarm coding was inaccurate and should have been coded as used daily. Resident R70 had diabetes, COPD, and high blood pressure. Quarterly MDS assessments coded insulin-related items as if insulin injections were received and insulin orders were changed, but the physician order record lacked evidence that insulin was ever ordered or administered. Resident R42 had atrial fibrillation, Parkinson’s disease, and COPD. The quarterly MDS with an ARD of 9/8/25 coded anticoagulant use as no, even though the physician ordered apixaban 5 mg twice daily and the MAR showed the resident received it twice daily throughout the 7-day lookback period. The RNAC confirmed the insulin and anticoagulant MDS entries were coded inaccurately.
Missing Care Plan for Insulin Use
Penalty
Summary
A comprehensive care plan was not developed for Resident R7 to address the resident's insulin use. The facility policy stated that care plans are to include measurable objectives and timetables to meet identified medical, nursing, mental, and psychosocial needs, and are to be reviewed quarterly, for significant changes, and after hospital returns. Resident R7 was admitted with diagnoses including diabetes, A-Fib, and schizoaffective disorder, and had a physician's order for Novolog 12 units subcutaneously every morning with breakfast, 12 units every afternoon with lunch, 10 units every evening, and sliding scale coverage with meals and at bedtime. The resident's annual MDS with an ARD of 10/30/25 indicated that insulin injections were received during the look-back period. However, the clinical record lacked evidence that a care plan had been developed to address the resident's use of insulin. During interview, the RNAC confirmed that a care plan had not been developed to address Resident R7's use of insulin.
Opened inhalers lacked required open dates on medication cart
Penalty
Summary
The facility failed to appropriately date and store medications in one of four medication carts reviewed, the C Hall Medication Cart. Review of the facility policy on Pharmaceutical Services and Medication Storage showed the facility was required to follow applicable state, federal, and local regulations regarding the storage, handling, and administration of medications. Manufacturer instructions for Trelegy Ellipta stated it should be discarded six weeks after opening the foil tray or when the counter read 0, whichever came first, and manufacturer instructions for Fluticasone Salmeterol (Advair Diskus) stated it should be discarded one month after the foil pouch was opened or when the counter read 0, whichever came first. During observation of the C-Hall Medication Cart, surveyors found one Trelegy Ellipta Diskus with the foil container opened, the diskus in use, and no open date, as well as one Fluticasone Salmeterol Diskus out of the foil package, in use, and also lacking an open date. At the time of the observation, an LPN confirmed that both medications were opened, in use, and did not have an open date.
Medication Storage and Access Deficiencies
Penalty
Summary
The facility failed to store Schedule II-V medications in a separately locked, permanently affixed compartment in three of four medication rooms reviewed. Specifically, in the medication rooms for wings A/B, C/D, and E/F, Lorazepam, a controlled antianxiety medication, was found in clear plastic locked boxes that were not permanently affixed to the refrigerator shelves, allowing for potential removal. Licensed Practical Nurses (LPNs) confirmed during interviews that the storage did not comply with the facility's policy requiring these medications to be stored in a permanently affixed, double-locked compartment. Additionally, the facility did not prevent unauthorized access to medications on two of four medication carts observed. On the D and F wing medication carts, open bottles of medications such as MiraLAX, Pepto-Bismol, and Robitussin were left on open shelves at the back of the carts, which were positioned facing the hallway and out of the nurse's view while attending to residents. LPNs confirmed that these medications should not have been accessible and should have been locked in the medication cart. Furthermore, the facility failed to appropriately discard outdated medications. An open pen of Lantus insulin on the E wing medication cart lacked an 'opened on' date, which is required to ensure the medication is used within the manufacturer's recommended timeframe. The LPN confirmed that without an opened date, the insulin should have been discarded, as per the facility's policy and manufacturer's guidelines.
Plan Of Correction
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 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.
Failure to Initiate Baseline Care Plan
Penalty
Summary
Pinecrest Manor was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the development and implementation of a baseline care plan for residents. The facility policy mandates that a baseline care plan should be developed for each resident within 48 hours of admission. However, it was determined that the facility failed to initiate a baseline care plan for one resident, identified as Resident R99, who was admitted on January 9, 2025. The resident's clinical record, which included diagnoses such as diabetes, high blood pressure, anemia, and acute kidney injury, lacked evidence of a baseline care plan being initiated. During an interview, the Nursing Home Administrator confirmed the absence of a baseline care plan in Resident R99's clinical record. This deficiency was identified through a review of facility policy, clinical records, and staff interviews. The failure to initiate a baseline care plan for Resident R99 indicates a lapse in adhering to the facility's policy and federal regulations, which require the development of a person-centered care plan within 48 hours of a resident's admission.
Plan Of Correction
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.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by interviews and observations. Resident R51, who requires assistance with mobility and transfers, reported waiting for an hour on the toilet for help and experiencing soiling due to delayed assistance. Additionally, during a Resident Council meeting, six alert and oriented residents expressed concerns about long wait times for call bell responses, particularly during the 3-11 shift and weekends. These residents have adapted by doing what they can for themselves, as they do not expect timely assistance. Further interviews revealed that Resident R12 had to wait until late morning for a shower and has not been walked by staff for months. Resident R34 reported not receiving a shower and sleeping in a recliner to manage bathroom needs independently. Resident R80, who has a physician's order for walking three times a week, has not been walked since January due to restorative aides being reassigned to work as nurse aides. Observations confirmed that restorative staff are often pulled to cover nursing shortages, limiting their ability to perform restorative duties effectively.
Plan Of Correction
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 in 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 re-educated 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.
Failure to Maintain Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care for a resident identified as R13. The resident, who was admitted with Alzheimer's Disease, venous stasis, and congestive heart failure, was observed receiving wound care. During the procedure, an LPN donned a clean gown and gloves, removed the resident's sock, and changed gloves multiple times without performing hand hygiene between glove changes. This occurred four times throughout the dressing change, contrary to the facility's hand hygiene policy. Additionally, an RN assisted in the procedure by positioning the resident's leg and handling the garbage can without performing hand hygiene before donning new gloves. The RN used bare hands to move the garbage can and then donned gloves to continue the procedure, failing to perform hand hygiene after touching the garbage can. Both the RN and LPN confirmed during an interview that they should have performed hand hygiene before donning clean gloves, as per the facility's policy.
Plan Of Correction
Resident R13 will be examined by the physician's assistant to ensure there were no negative outcomes. Employee El 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. 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. 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. 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. The corrective action plan will be fully implemented by April 10, 2025.
Nurse Aide Staffing Deficiency on Evening and Overnight Shifts
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios for both the evening and overnight shifts on November 30, 2024. Specifically, during the evening shift, the facility had a census of 101 residents but only 8.05 NAs worked, whereas 9.18 were required to meet the regulation of one NA per 11 residents. Similarly, for the overnight shift, the facility had 6.37 NAs working when 6.73 were required to meet the regulation of one NA per 15 residents. This staffing shortage was confirmed by the Nursing Home Administrator during a telephone interview on December 23, 2024.
Plan Of Correction
1. Review and Revise Staffing Plans: - Daily Staffing Assessment: A daily staffing review will be scheduled to assess daily census levels, staffing requirements, and any gaps. This will ensure sufficient staffing is planned each day based on the census. - Shift Adjustments: Shift adjustments or additional NA staff will be scheduled proactively, especially during peak times, holidays, or any days expected to have higher resident needs. 2. Training & Education: - Staff Education and Staffing Protocols: Educate all managerial and supervisory staff on how to monitor staffing levels and staff ratios throughout the day and night shifts and to take appropriate action to prevent shortfalls and adhere to state-required staffing ratios. 3. Monitoring and Audits: - Weekly Audits: The facility will implement a weekly audit of staffing records to ensure that staffing ratios are met. The Nursing Home Administrator will review staffing ratios against census levels to monitor compliance. - Audit Reviews: The audit findings will be discussed in the quarterly quality assurance meetings. 4. Corrective Action Plan Implementation & Monitoring: - The Nursing Home Administrator and Director of Nursing will be responsible for overseeing the implementation of the corrective actions. 5. Completion Date: - All corrective actions will be implemented immediately, with a review and audit completed by 2/23/2025 to ensure compliance.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. This deficiency was identified during a review of the facility's nursing staffing documents for the period from November 21, 2024, to December 4, 2024. Specifically, on November 30, 2024, the facility provided only 2.94 hours of direct nursing care per resident, falling short of the mandated minimum. This shortfall was confirmed during a telephone interview with the Nursing Home Administrator on December 23, 2024.
Plan Of Correction
1. Review and Revise Staffing Plans: - Daily Staffing Assessment: A daily staffing review will be scheduled to assess daily census levels. This will ensure sufficient staffing is planned each day based on the census. - Shift Adjustments: Shift adjustments or additional staff will be scheduled proactively on days expected to have higher resident needs. 2. Training & Education: - Staff Education and Staffing Protocols: Educate all managerial and supervisory staff on how to monitor staffing levels, staff ratios throughout the day and night shifts, and to meet a minimum of 3.2 hours of direct resident care hours and to take appropriate action to prevent shortfalls and adhere to state-required staffing ratios. 3. Monitoring and Audits: - Weekly Audits: The facility will implement a weekly audit of staffing records to ensure that the 3.2 minimum hours of direct resident care for each resident are met. The Nursing Home Administrator will review staffing ratios and resident care hours are met against census levels to monitor compliance. - Audit Reviews: The audit findings will be discussed in the quarterly quality assurance meetings. 4. Corrective Action Plan Implementation & Monitoring: - The Nursing Home Administrator and Director of Nursing will be responsible for overseeing the implementation of the corrective actions. 5. Completion Date: - All corrective actions will be implemented immediately, with a review and audit completed by 2/23/2025 to ensure compliance.
Failure to Initiate Baseline Care Plan and Provide Written Summary
Penalty
Summary
The facility failed to initiate a baseline care plan for one resident and did not provide a written summary of the baseline care plan and order summary to another resident or their representative. Resident R201, who was admitted with diagnoses including diabetes, high blood pressure, and peripheral arterial disease, did not have a baseline care plan initiated within the required 48-hour timeframe. This was confirmed by the Nursing Home Administrator. Additionally, Resident R99, admitted with a history of stroke, cardiovascular disease, history of falling, and anxiety, did not receive a written summary of the baseline care plan and order summary. This was confirmed by the Director of Nursing.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for one of the residents reviewed, identified as Resident R7. The facility's policy requires a comprehensive care plan that includes measurable objectives and timetables to meet the medical, nursing, mental, and psychosocial needs of residents. Resident R7, who was admitted with diagnoses including Alzheimer's Dementia, Seizures, and High Blood Pressure, had a physician's order for a Wanderguard bracelet to prevent elopement. However, the clinical record lacked evidence of a care plan addressing Resident R7's risk for wandering or elopement and the use of the Wanderguard bracelet. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Properly Date and Discard Medications
Penalty
Summary
The facility failed to ensure that medications were properly dated when opened and discarded in a timely manner. Specifically, in the Unit A/B medication storage room, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the discard date. This was confirmed during an interview with an LPN, who acknowledged the missing open date on the vial. The facility policy and manufacturer's recommendations both require that vials be discarded 30 days after being opened, but this protocol was not followed in this instance.
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Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St Marys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elk Haven Nursing Home | 0.2 mi | ★★★★★ | 6 | 0 |
| Highland View Rehabilitation & Healthcare Center | 17 mi | ★★★★★ | 7 | 0 |
| Guy And Mary Felt Manor, Inc | 18.6 mi | ★★★★★ | 0 | 0 |
| Lutheran Home At Kane, The | 19.8 mi | ★★★★★ | 6 | 0 |
| Dubois Nursing Home | 23.3 mi | ★★★★★ | 22 | 0 |
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