Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Retirement Community during CMS and state inspections, most recent first.
Two CNAs failed to follow proper infection control practices during incontinent care for a resident with chronic conditions, cognitive impairment, continuous incontinence, and a documented UTI. Surveyors observed both CNAs enter the resident’s room without performing hand hygiene, don gloves, and complete the entire perineal care procedure—including handling a urine-soiled brief, cleansing the perineal and rectal areas, applying barrier ointment, and adjusting clothing—without changing gloves between dirty and clean tasks. In interviews, the CNAs reported they believed gloves only needed to be changed if visibly soiled with feces, despite having prior skills check-offs in perineal care and infection control, while facility leadership confirmed that these actions were inconsistent with established hand hygiene and glove-change requirements.
A resident on contact isolation and Enhanced Barrier Precautions for an MDRO, with chronic systolic heart failure, anemia, osteoporosis, moderate cognitive impairment, and total urinary/bowel incontinence, received incontinent care during which two CNAs failed to follow the facility’s infection control policies. They entered the room with a posted contact precautions sign, did not perform hand hygiene before care, wore only gloves without gowns, and did not change gloves when moving from cleaning soiled areas to handling clean briefs and applying barrier ointment. Interviews showed both CNAs misunderstood glove use and did not attend to the isolation signage, despite prior competency check-offs, while leadership confirmed that facility policy requires gowns and gloves for high-contact care under EBP, glove changes between dirty and clean tasks, and hand hygiene before, during, and after resident contact.
Dietary staff did not consistently test or log dish machine sanitizing temperatures, and food was served without verifying proper holding temperatures in the main and satellite kitchens. Staff also used improper food handling techniques, such as serving food with gloved hands after touching other surfaces, and failed to follow facility policies for temperature monitoring and utensil use.
The facility failed to maintain sanitary conditions in the kitchen, with undated and expired soda syrup concentrates connected to the drink dispenser and improperly labeled and expired foods in the freezer. The Dining Director acknowledged the oversight and the need for proper labeling and removal of expired items.
The facility failed to ensure that three dietary staff members had current food handler certifications, which could place residents at risk of food-borne illness. The Dining Director and Administrator acknowledged the oversight, and the facility's policy requires that all personnel maintain current certifications in their personnel records.
The facility failed to ensure an accurate MDS assessment for a resident, who was incorrectly coded as having restraints. The error was identified during an audit, and the MDS assessment was subsequently modified to reflect the accurate status of the resident.
A facility failed to develop and implement a baseline care plan within 48 hours for a resident admitted with a femur fracture. The care plan was completed 18 days late, and the resident's family was not provided with a summary. Staff interviews revealed inconsistencies in managing the responsibility for completing baseline care plans, leading to delays and potential care delivery issues.
A resident with severe cognitive impairment and a history of falls was left unattended in a sit-to-stand lift by a CNA, resulting in a fall. The CNA left the room to retrieve supplies, and upon return, found the resident on the floor. The resident was assessed for injuries, and none were found. The CNA was suspended and later terminated, and the facility conducted in-service training on proper lift use.
A facility failed to ensure safe and sanitary storage of a resident's food items, leading to the presence of expired cheese sticks, prune juice, and nutritional shakes in the resident's personal refrigerator. Staff inconsistently checked for expired foods, focusing mainly on temperature logs, despite the facility's policy requiring the disposal of opened or dated items after three days.
A CNA failed to sanitize or wash hands between glove changes while providing incontinent care to a resident with severe cognitive impairment and incontinence. This lapse in infection control protocol was observed and confirmed through interviews, highlighting a deficiency in the facility's infection prevention and control program.
Failure to Ensure CNA Competency in Hand Hygiene and Glove Use During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that certified nurse aides (CNAs) possessed and demonstrated appropriate infection control competencies, specifically hand hygiene and glove use, during incontinent care. Surveyors observed two CNAs (A and B) enter the room of Resident #8 without performing hand hygiene and immediately don gloves. They then conducted the entire incontinent care procedure without changing gloves, despite handling soiled items and then moving to clean tasks and clean items. Resident #8 had been recently admitted with diagnoses including chronic systolic heart failure, anemia, and osteoporosis. A Significant Change MDS assessment documented moderate cognitive impairment with a BIMS score of 10, a need for partial/moderate assistance with toileting hygiene, and continuous urinary and bowel incontinence. Her care plan, revised shortly before the observation, identified a UTI and included interventions to check for incontinence at least every two hours, indicating ongoing incontinence management needs. During interviews, both CNAs acknowledged they had received skills check-offs on hire, including perineal care and infection control, but each stated they believed they could continue using the same gloves as long as they were not visibly soiled with feces. They both recognized, when questioned, that gloves should be changed after handling dirty items and that failure to do so could result in cross-contamination. Facility leadership, including the ADON/IP, DON, and Administrator, stated that staff were trained on infection control, that hand hygiene should be performed before, during, and after care, and that gloves should be changed between dirty and clean tasks, confirming that the observed practices by CNAs A and B did not comply with facility policy and competency expectations for infection control.
Failure to Follow Contact Precautions and Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program for a resident on contact precautions and Enhanced Barrier Precautions (EBP). The resident was an older adult admitted with chronic systolic heart failure, anemia, and osteoporosis, and had active physician orders for EBP related to a multidrug-resistant organism (MDRO) and an abnormal urinalysis, with contact isolation precautions in place. Her care plan documented contact isolation precautions and the need to follow the facility’s isolation policy. A Significant Change MDS showed she had moderate cognitive impairment and was always incontinent of bowel and bladder, requiring partial to moderate assistance with toileting hygiene. During an observed episode of incontinent care, two CNAs entered the resident’s room, which had a contact precautions sign posted and contained PPE supplies including gowns, N95 masks, face shields, and biohazard bags. Neither CNA performed hand hygiene before starting care, and both donned only gloves without gowns despite the contact precautions order. One CNA pulled down the resident’s pants and brief and performed perineal cleansing of the inner thighs and vaginal area, while the other CNA rolled the resident, cleansed the rectal area, removed the soiled brief, and then placed a clean brief under the resident and applied barrier ointment without changing gloves between handling soiled items and clean items. One CNA washed her hands only after removing gloves at the end of care, and the other CNA removed gloves and discarded them without documented hand hygiene. In subsequent interviews, both CNAs acknowledged they did not pay attention to the contact precautions sign, did not wear gowns, did not perform hand hygiene before care, and did not change gloves when moving from dirty to clean tasks, stating they believed gloves could be worn throughout care if not visibly soiled with feces. They each had prior competency checklists indicating they had been observed performing perineal care and infection control. The ADON, serving as the Infection Preventionist, and the DON described facility policies and expectations that staff wear gowns and gloves for residents on contact precautions or EBP during high-contact care such as changing briefs, perform hand hygiene before, during, and after care, and change gloves between dirty and clean tasks, consistent with the facility’s written policies on Enhanced Barrier Precautions, Isolation/Transmission-Based Precautions, and Handwashing/Hand Hygiene.
Failure to Maintain Sanitary Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the main kitchen and all three satellite kitchens. Dietary staff did not accurately test or log dish machine temperatures for hot water sanitizing on multiple occasions, and there were missing entries for several meal periods. Observations revealed that the dish machine temperatures were below required sanitizing levels, and staff did not consistently communicate these discrepancies to management. Additionally, dishware and silverware were washed and returned to satellite kitchens without proper temperature verification, and the facility's own policy required documentation of these temperatures at each meal period. Food service staff did not consistently take or record holding temperatures before serving food to residents. On several occasions, food was served without verifying that it was at the appropriate holding temperature, including both main and alternate food items. In some cases, food items such as chicken strips, French fries, and pureed meals were found to be below the required serving temperatures, yet were still served to residents. Staff interviews confirmed that temperatures were not always checked or recorded as required by facility policy. Sanitary food handling practices were also not followed. Staff were observed using gloved hands to serve food items after touching other surfaces and utensils, without changing gloves between tasks. This included handling rolls, French fries, chicken strips, and onion rings. Staff demonstrated a lack of understanding regarding the need to change gloves and use utensils for serving food, as required by facility policy. These failures in food storage, preparation, temperature monitoring, and handling could place residents at risk of foodborne illness.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the main kitchen. During an observation, six containers of concentrated soda syrup connected to the drink dispenser were found without documented opened dates, and three containers were expired. The Dining Director, who had been working at the facility for two months, acknowledged the oversight and stated that he was responsible for discarding expired items. Additionally, the freezer contained improperly labeled and expired foods, including a clear zip lock bag of frozen chicken with no use-by date, a bag of beef stock with an expired use-by date, and an unlabeled bag of frozen fish. The Dining Director admitted responsibility for training the dietary staff and ensuring proper labeling and removal of expired items. Interviews with the Dining Director and the Administrator confirmed that serving expired foods could cause illness and that it was the responsibility of the Dietary Director to ensure all expired food was removed from the kitchen. The facility's Food Safety and Quality Assurance Standards Manual indicated that expired foods must be discarded and not used or served. The Dining Director mentioned that an in-service training for dietary staff regarding labeling and removing expired items had begun, emphasizing the importance of all team members adhering to these standards.
Failure to Ensure Dietary Staff Had Current Food Handler Certifications
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, three dietary staff members (Dietary Staff D, E, and F) did not have current food handler's certificates while working in the facility's kitchen. This was discovered during a review of records and interviews conducted between 04/29/24 and 05/01/24. The Dining Director acknowledged that it was his responsibility to ensure all kitchen staff had current food handler certifications and admitted that the three employees did not have the necessary certifications. The Administrator also confirmed that she expected all dietary staff to have updated food handler certificates and receive training to prevent food-borne illness. The facility's policy requires that personnel who need a license, certification, or registration to perform their duties must present verification upon employment and maintain current certifications in their personnel records. The deficiency was identified through a review of 28 dietary staff members' food handler certificates, which revealed that Dietary Staff D, E, and F did not have current certifications. The Dining Director stated that he had spoken with the three employees, who confirmed they did not have current food handler certifications. The facility's policy mandates that employees present verification of required certifications to the Human Resources Director or designee prior to or upon employment and maintain current certifications in their personnel records. The failure to ensure that these dietary staff members had current food handler certifications could place all residents who consumed food prepared in the kitchen at risk of food-borne illness.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident, who was incorrectly coded as having restraints. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was documented as using physical restraints in bed, which was not the case. The Director of Nursing (DON) confirmed that the facility was restraint-free and that no residents, including the one in question, had restraints. The MDS Coordinator admitted to accidentally checking the restraint box on the MDS assessment and stated that she had modified the assessment to correct the error after it was brought to her attention. The Regional MDS Coordinator, who audits the facility's MDS assessments quarterly, also confirmed that the facility was restraint-free and that the incorrect coding should have been caught by the MDS Coordinator. The Administrator acknowledged the error and mentioned that the facility's policy requires all portions of the MDS to be certified for accuracy by the responsible staff. The incorrect coding was identified during an audit, and the MDS assessment was subsequently modified to reflect the accurate status of the resident.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by regulations. Specifically, a male resident admitted with a diagnosis of aftercare for a femur fracture did not have his baseline care plan completed until 18 days after admission. Additionally, the resident's family was not provided with a summary of the baseline care plan. Interviews with staff, including an LVN, MDS Coordinator, DON, and the Administrator, revealed that the responsibility for completing the baseline care plans was not consistently managed, leading to delays and potential care delivery issues. The LVN responsible for completing the baseline care plans admitted to sometimes falling behind, while the MDS Coordinator and DON confirmed that the admitting nurse or weekend supervisor should complete the care plans within the required timeframe. The Administrator acknowledged that the previous system for completing baseline care plans was not effective and that the current process would be reviewed for compliance. The facility's policy, dated December 2016, mandates that a baseline care plan be developed within 48 hours of admission and that a summary be provided to the resident or their representative, which was not adhered to in this case.
Inadequate Supervision During Transfer
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required substantial assistance with transfers. On the specified date, a CNA left the resident standing in a sit-to-stand lift unattended to retrieve supplies, resulting in the resident falling. The resident had a history of falls, muscle weakness, and severe cognitive impairment, necessitating careful supervision during transfers. The incident occurred when the CNA noticed the resident was wet and used the sit-to-stand lift to provide care. Upon realizing that wipes were needed, the CNA left the resident unattended in the lift to search for wipes in another room and at the nurse's station. The CNA returned to find the resident on the floor, having fallen from the lift. The resident was assessed for injuries, and none were found. Interviews with staff revealed that the facility's policy required 1-2 person assistance for using the sit-to-stand lift, depending on the resident's condition. The CNA involved was suspended and later terminated. The facility conducted in-service training on the proper use of lifts and fitting slings correctly following the incident. Observations and interviews confirmed that staff were aware of the need for proper supervision and assistance during transfers, but the incident highlighted a lapse in following these protocols.
Failure to Ensure Safe and Sanitary Storage of Resident's Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident. The resident, a male with diagnoses including scoliosis, chronic pain, and anemia, had expired food items in his refrigerator, including cheese sticks, prune juice, and nutritional shakes. Despite the resident's efforts to keep the refrigerator clean and monitor temperatures, expired items were found during an inspection. Staff members, including LVNs and CNAs, were responsible for checking the personal refrigerators but failed to consistently check for expired foods, focusing instead on temperature logs. This inconsistency led to the presence of expired food items in the resident's refrigerator. Interviews with various staff members revealed that while some staff checked the personal refrigerators for expired foods, others only checked temperature logs. The facility's policy required that all opened or dated items be discarded after three days, but this was not consistently enforced. The ADON and DON were supposed to make rounds to ensure compliance, but expired items were still found in the resident's refrigerator. The facility's administration acknowledged that residents were responsible for their personal refrigerators, but nursing staff were expected to ensure compliance with the policy, which was not effectively done in this case.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of CNA A during the provision of incontinent care to Resident #6. CNA A did not sanitize or wash hands between glove changes, which is a critical step in preventing the transmission of infections. During the care, CNA A removed gloves and applied new ones without performing hand hygiene, despite being trained on proper infection control protocols. This lapse was observed during an incident where CNA A and CNA B were providing care to Resident #6, who has severe cognitive impairment and is always incontinent of bowel and bladder. Resident #6, who has diagnoses including dementia, anemia, and hypertension, required substantial assistance with activities of daily living. The care plan for Resident #6 included cleaning the peri-area with each incontinence episode. Despite this, CNA A failed to follow proper hand hygiene protocols, which was confirmed during interviews with CNA A, the ADON, and the Administrator. The facility's policy on hand hygiene, which emphasizes the importance of hand washing to prevent the spread of infections, was not adhered to in this instance.
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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 Lufkin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkwood In The Pines | 1.9 mi | ★★★★★ | 11 | 0 |
| Kennedy Health & Rehab | 2.2 mi | ★★★★★ | 14 | 7 |
| Castle Pines Health And Rehabilitation | 2.2 mi | ★★★★★ | 1 | 1 |
| Larkspur | 2.6 mi | ★★★★★ | 3 | 0 |
| Southland Rehabilitation And Healthcare Center | 2.9 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.