Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
95 residents
Based on a April 2025 inspection.
Occupancy over time
Inspection Report
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
The inspection was conducted to evaluate compliance with discharge and transfer procedures following concerns about a resident's behavioral issues and the facility's notification and bed-hold policies.
Findings
The facility failed to follow proper discharge procedures for a resident transferred to an acute hospital, including failure to notify the resident's responsible party of the intent to discharge and failure to offer a bed-hold. This resulted in the resident being denied return to the facility and disruption of care.
Deficiencies (1)
Failure to provide required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Report Facts
Date of survey completion: Jul 23, 2025
Brief Interview for Mental Status (BIMS) score: 4
Medication dosage: 6.25
Medication dosage: 12.5
Resident admission date: 202506
Inspection Report
Routine
Census: 95
Deficiencies: 10
Date: Apr 11, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, hygiene, hydration, and documentation at Pine Creek Care Center.
Findings
The facility failed to develop and implement appropriate care plans, provide ordered treatments such as TED hose and compression devices, maintain proper hygiene and hydration for residents, accurately document medication administration, secure medications properly, and safeguard resident confidentiality. Several residents did not receive ordered care or supervision, and documentation errors were noted.
Deficiencies (10)
Failure to develop and implement a care plan for Resident 79's G-tube.
Failure to apply TED hose and lymphatic compression devices as ordered for Residents 82, 25, and 67.
Failure to provide proper hygiene for Residents 30 and 38, including untrimmed fingernails and dry, scaly skin.
Failure to accurately account for controlled medications for Residents 30, 38, and 51.
Medication carts found unlocked and unattended; presence of unlabeled medication; discontinued medications not removed timely.
Failure to provide sufficient hydration for Residents 13, 298, 299, and 300 due to missing bedside water pitchers.
Failure to provide 1:1 supervision and assistance during meals for Resident 79 as ordered.
Failure to accurately document administration of TED hose and IV antibiotics; staff documented treatments not provided.
Resident meal tickets containing confidential information were disposed of in regular garbage instead of confidential shredding.
Inaccurate informed consent documentation for Resident 48's psychotropic medication.
Report Facts
Residents sampled: 27
Facility census: 95
Fluid intake: 680
Fluid intake: 330
BIMS score: 11
BIMS score: 8
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 3 | Licensed Nurse | Acknowledged Resident 79 had a G-tube without current physician order or care plan |
| Licensed Nurse 4 | Licensed Nurse | Confirmed Resident 82 was not wearing TED hose or compression device and admitted documenting treatments not provided |
| Licensed Nurse 6 | Licensed Nurse | Acknowledged documenting application of TED hose for Residents 25 and 67 when not applied |
| Licensed Nurse 7 | Licensed Nurse | Documented administration of IV antibiotics for Resident 249, which was inaccurate |
| Director of Nursing | Director of Nursing | Reviewed records and confirmed expectations for accurate documentation and following physician orders |
| Assistant Director of Nursing | Assistant Director of Nursing | Reviewed informed consent documentation and confirmed it was incomplete |
| Nurse Practitioner | Nurse Practitioner | Stated expectation for nursing staff to follow resident orders as written |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Described responsibilities for providing water pitchers and noted no missing pitchers observed |
| Treatment Nurse | Treatment Nurse | Confirmed poor hygiene findings for Residents 30 and 38 |
| Dietary Manager | Dietary Manager | Confirmed meal tickets with resident confidential information were disposed of improperly |
| Physical Therapy Assistant | Physical Therapy Assistant | Confirmed Resident 67 had no TED hose available |
Inspection Report
Routine
Census: 91
Deficiencies: 8
Date: Apr 19, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, medication administration, infection control, and food safety at Pine Creek Care Center.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete care plans, failure to implement physician orders, improper medication labeling, inadequate food storage and sanitation practices, and lapses in infection prevention and control procedures.
Deficiencies (8)
Failed to ensure accurate assessments for two residents, resulting in inaccurate Minimum Data Set (MDS) coding.
Failed to develop and implement accurate baseline care plans for three residents within 48 hours of admission.
Failed to revise a care plan to reflect placement of an elopement management bracelet for one resident.
Failed to ensure services met professional nursing standards including implementation of physician orders and proper care of PICC lines and elopement bracelets.
Failed to assist a resident to an upright position while eating, increasing risk of aspiration.
Failed to ensure all drugs were properly labeled in medication carts, risking medication errors.
Failed to meet food storage and service practices including unlabeled opened food packages, unsealed packaging, and inadequate sanitizer solution concentration.
Failed to provide and implement an effective infection prevention and control program, including lapses in hand hygiene, equipment disinfection, and labeling of resident equipment.
Report Facts
Residents sampled: 24
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents census: 91
Sanitizer solution ppm: 100
Sanitizer solution ppm: 150
Sanitizer solution ppm: 100
Sanitizer solution ppm: 100
Sanitizer solution ppm: 150
Sanitizer solution ppm: 150
Sanitizer solution ppm: 150
Sanitizer solution ppm: 150
Sanitizer solution ppm: 150
Sanitizer solution ppm: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 3 | CNA | Confirmed contracted knees of Resident 15 during repositioning |
| Licensed Nurse 4 | LN | Confirmed contracted knees of Resident 15 |
| MDS Coordinator | MDSC | Confirmed inaccurate MDS assessments for Residents 15 and 301 |
| Licensed Nurse 5 | LN | Confirmed inaccurate MDS for Resident 301 |
| Director of Nursing | DON | Confirmed expectations for accurate assessments and care plans |
| Certified Nursing Assistant 5 | CNA | Unaware of elopement bracelet on Resident 310 |
| Assistant Director of Nursing | ADON | Confirmed missing care plans and incomplete implementation of physician orders |
| Licensed Nurse 7 | LN | Confirmed PICC dressing needed changing |
| Licensed Nurse 8 | LN | Observed PICC dressing and discussed monitoring orders |
| Licensed Nurse 9 | LN | Confirmed unlabeled oxygen tubing, nebulizer tubing, and urinals |
| Director of Staff Development | DSD | Stated expectations for oxygen tubing and nebulizer labeling |
| Restorative Nursing Assistant Supervisor | RNAS | Stated expectations for urinal labeling |
| Licensed Nurse 1 | LN | Observed lapses in hand hygiene during medication administration |
| Certified Nursing Assistant 1 | CNA | Observed lapses in hand hygiene and equipment disinfection |
| Food and Nutrition Director | FND | Observed food safety and sanitizer solution deficiencies |
| Food and Nutrition Assistant | FNA | Observed unlabeled food items and sanitizer solution below effective range |
| Laundry Attendant | LA | Failed to disinfect washing machine exterior after loading dirty laundry |
| Regional Nurse Consultant 1 | RNC | Confirmed unlabeled medication in medication cart |
| Medical Doctor | MD | Unaware of elopement bracelet order for Resident 310 |
| Nurse Practitioner | NP | Confirmed no documentation of elopement bracelet order |
Inspection Report
Routine
Deficiencies: 7
Date: Apr 19, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control standards, including hand hygiene, equipment sanitation, and labeling of medical devices.
Findings
The facility failed to follow infection control standards in multiple areas including improper hand hygiene during medication administration, inadequate disinfection of equipment such as vital signs machines and washing machines, unlabeled oxygen tubing and nebulizer equipment, and unlabeled urinals. These deficiencies increased the risk of cross-contamination and infection spread.
Deficiencies (7)
Staff did not perform hand hygiene prior to donning and after doffing PPE during medication administration.
Shower chair with brown substance was stored without following recommended disinfectant contact time.
Staff did not sanitize the exterior surface of the washing machine including the door handle after loading dirty laundry.
Staff did not disinfect the vital signs machine between resident use and after use.
Oxygen tubing was not labeled with a date for Residents 6, 36, and 95.
Nebulizer equipment was not labeled with a date or stored in an anti-microbial bag for Resident 6.
Urinals were not labeled with resident identifiers for Residents 6 and 7.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Licensed Nurse | Observed not performing proper hand hygiene during medication administration. |
| Certified Nursing Assistant 1 | CNA | Observed not performing hand hygiene and disinfecting vital signs machine between resident use. |
| Certified Nursing Assistant 4 | CNA | Confirmed presence of brown substance on shower chair and improper disinfectant contact time. |
| Laundry Attendant | Laundry Attendant | Observed not sanitizing washing machine exterior after loading dirty laundry. |
| Licensed Nurse 9 | Licensed Nurse | Confirmed unlabeled oxygen tubing, nebulizer equipment, and urinals. |
| Director of Nursing | DON | Stated expectations for hand hygiene, equipment cleaning, and labeling of oxygen tubing and nebulizer equipment. |
| Director of Staff Development | DSD | Stated expectations for weekly replacement and labeling of oxygen tubing and nebulizer equipment. |
| Restorative Nurse Assistant Supervisor | RNAS | Stated expectations for labeling urinals to prevent cross-contamination. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure professional standards of practice in medication administration for a resident with Parkinson's disease.
Complaint Details
The complaint investigation found that medication doses for Resident 1 were missed or administered late, confirmed by the Assistant Director of Nursing who acknowledged the potential for negative side effects and that the facility's standards were not met.
Findings
The facility failed to administer carbidopa-levodopa medication on time for Resident 1, resulting in missed and late doses that could cause negative side effects such as worsening tremors and increased rigidity. The Assistant Director of Nursing confirmed these medication administration failures did not meet the facility's standards of care.
Deficiencies (2)
A physician's order for carbidopa-levodopa was discontinued and not reordered for 11 hours, causing a missed dose.
One dose on 6/22/23, two doses on 6/25/23, and one dose on 7/1/23 of carbidopa-levodopa were administered late.
Report Facts
Medication administration delay: 11
Late medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed and confirmed medication administration failures and standards of care |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 1
Date: Aug 9, 2023
Visit Reason
The inspection was conducted following a complaint alleging that residents were left in wet briefs and not properly cared for during the PM shift on 7/25/23.
Complaint Details
The complaint was substantiated based on interviews and observations confirming residents were left in wet briefs during the PM shift on 7/25/23, with staff failing to respond to call lights and remove wet briefs or transfer slings.
Findings
The facility failed to ensure residents' dignity by leaving three residents in urine-soaked briefs and one resident lying on a wet transfer lift sling. This neglect caused discomfort and increased risk of skin issues for confused residents.
Deficiencies (1)
Residents were left in urine-soaked briefs and wet transfer lift sling, compromising dignity and care.
Report Facts
Residents affected: 3
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | PM shift nurse on 7/25/23 who checked residents and found wet briefs |
| LN 2 | Licensed Nurse | Night shift nurse who confirmed dignity issues with wet briefs |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 5
Date: Apr 15, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to develop a care plan for a lymphedema compression pump, failure to notify the physician of a broken medical device and obtain alternative intervention, medication errors exceeding 5%, and unsafe food preparation and handling practices.
Complaint Details
The complaint investigation focused on Resident 62's care plan and medical device use, and Resident 284's medication administration errors. The investigation found substantiated deficiencies related to care planning, notification of broken medical equipment, medication errors, and food safety practices.
Findings
The facility failed to develop a care plan for the use of a lymphedema compression pump for Resident 62, failed to notify the physician about the broken pump and did not provide alternative intervention, had a medication error rate of 6.67% due to late administration of insulin for Resident 284, and failed to maintain sanitary conditions in food preparation including improper ice machine sanitation, unlabeled resident food, and inadequate dishwasher sanitizing procedures.
Deficiencies (5)
Failure to develop a care plan for the use of a lymphedema compression pump for Resident 62.
Failure to notify physician of broken lymphedema pump and failure to obtain alternative intervention for Resident 62.
Medication error rate exceeded 5% due to late administration of insulin for Resident 284.
Failure to ensure Resident 284 was free from significant medication errors when insulin was administered late.
Failure to maintain sanitary conditions of the ice machine, unlabeled resident food stored in nursing station refrigerator, and failure to follow sanitizing procedure for dishwasher.
Report Facts
Residents sampled: 19
Facility census: 89
Medication error rate: 6.67
Medication opportunities: 30
Medications not administered: 2
Resident 62 pump application dates: 3
Resident 27 discharge date: Mar 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 2 | Licensed Nurse | Confirmed lymphedema pump use and lack of care plan for Resident 62 |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Confirmed expectation for care plan development and lack of alternative intervention for Resident 62 |
| Licensed Nurse 1 | Licensed Nurse | Administered medications late to Resident 284 and acknowledged delay |
| Director of Nursing | Director of Nursing | Discussed best practices for medication administration timing |
| Maintenance Supervisor | Maintenance Supervisor | Confirmed ice machine cleaning procedures and sanitizer use |
| Licensed Nurse 3 | Licensed Nurse | Observed unlabeled food in nursing station refrigerator |
| Registered Dietitian | Registered Dietitian | Observed dishwasher technician's inability to demonstrate sanitizer concentration testing |
| Dishwasher Technician | Dishwasher Technician | Unable to demonstrate sanitizer concentration testing or identify sanitizer chemical |
| Food Service Manager | Food Service Manager | Participated in dishwasher sanitizing procedure observation |
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