Health inspection·March 14, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted 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 Page 1 of 3 395279 395279 03/14/2024 Pinecrest Manor 763 Johnsonburg Rd St Marys, PA 15857

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 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). Residents Affected - Few 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 395279 Page 2 of 3 395279 03/14/2024 Pinecrest Manor 763 Johnsonburg Rd St Marys, PA 15857

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. 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 395279 Page 3 of 3