Inspection Reports for
Pine Knoll Nursing & Rehab Ctr

The investigation included multiple complaint intake numbers (GA00253152, GA00253289, GA00253343, GA00253508, GA00253684) and was conducted in conjunction with the standard survey.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to properly label and discard food items, improper food storage, and failure to ensure proper hand hygiene among staff, which could potentially affect resident safety and infection control.

The facility was found deficient in ensuring proper hand hygiene among staff during resident care, posing a risk of infection spread. Additionally, the facility failed to properly discard expired food, label opened food items, and follow recipes for puree foods, potentially affecting 102 residents on an oral diet.

The facility was found not in substantial compliance with the Life Safety Code requirements, including missing sprinkler escutcheon in the kitchen, illegible sprinkler system data design plate, unsealed penetration in a fire/smoke barrier, and failure to perform the required 4-hour load test for the emergency generator within the last 36 months.

The complaint investigation was initiated due to multiple complaint allegations. GA00238750 and GA00235000 were unsubstantiated. GA00238940 was substantiated with no deficiency. GA00235307 was substantiated with a citation of F658 related to medication administration failure for resident R11.

The investigation substantiated one complaint with a citation (F658) related to failure to follow physician orders for medication administration for one resident (R11), who did not receive prescribed inhaler medication on 5/12/2023 and 5/13/2023. Other complaints were unsubstantiated or substantiated with no deficiency.

The facility was found not in substantial compliance with fire safety requirements, including improper installation of the fire alarm system, corridor doors failing to close properly, and failure to perform and document quarterly fire drills.

The facility was found deficient in multiple areas including improper storage and labeling of medications, unsecured medication carts with resident information visible, failure to count controlled substances properly, improper storage of nebulizer masks, and unsanitary conditions due to buildup of white fuzzy material on bathroom vent covers.

Complaint Intake Numbers GA00231867 and GA00231685 were investigated in conjunction with the standard survey.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain resident dignity related to urinary catheter privacy bags, unsafe sanitary conditions due to buildup on bathroom vents, medication storage and labeling issues, unsecured medication carts, and improper storage of nebulizer masks.

The facility was found to have corrected all previously cited survey tags except for deficiencies related to the Emergency Preparedness Training Program, specifically the lack of documentation for initial and ongoing emergency preparedness training for staff, individuals providing services under arrangement, and volunteers.

The facility failed to ensure proper medication management including dating opened medications, labeling biologicals, and discarding expired medications. The facility also failed to follow COVID-19 screening protocols for staff and visitors, and failed to provide effective infection control practices during medication administration. Additionally, deficiencies were found in nursing care related to respiratory status documentation, oxygen therapy care plans, and dialysis communication and assessments.

The facility was found not in substantial compliance with multiple regulatory requirements including comprehensive care planning, respiratory and tracheostomy care, dialysis care, medication labeling and storage, infection prevention and control, and staff screening procedures. Deficiencies included failure to follow care plans, lack of physician orders for oxygen therapy, expired medications, inadequate infection control practices, and failure to properly screen staff and visitors for COVID-19.

The facility was found not in substantial compliance with emergency preparedness requirements including lack of documentation for tracking staff and patients during emergencies, missing emergency contact information, inadequate emergency preparedness training and testing documentation, blocked egress pathways, and failure to perform monthly fire extinguisher inspections.

The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations due to failure to ensure residents' rooms were properly disinfected according to standard and transmission-based precautions. Issues included improper disinfectant dwell times and unlabeled or mislabeled disinfectant spray bottles on cleaning carts.

Complaint GA00198785 was unsubstantiated. Complaint GA00198398 was substantiated with the cited deficiency related to failure to timely report an injury of unknown source.

Complaint GA00198785 was unsubstantiated. Complaint GA00198398 was substantiated due to the facility's failure to notify the State Survey Agency within the required two-hour time period after a resident sustained an injury of unknown source, specifically a hematoma on the resident's forehead.

The survey revealed the facility was not in substantial compliance with regulations. Key findings included a failure to ensure adequate supervision and assistive devices to prevent falls for one resident who fell from a mechanical lift, and multiple sanitation and maintenance deficiencies in the kitchen that created potential for foodborne illness.

The facility failed to maintain the kitchen in a sanitary manner, with multiple sanitation issues including clogged sinks, inadequate dish machine sanitization, cracked and uncleanable floor tiles, soiled dishware storage, and damaged walls. Maintenance and service records showed ongoing issues with the dish machine and kitchen infrastructure.

The facility was found not in substantial compliance due to failure to provide a remote annunciator with storage battery backup hardwired to indicate alarm conditions of the emergency power source in a location readily observed by operating personnel, which could place residents at risk during a generator malfunction.

The facility was found not in substantial compliance with fire safety requirements due to failures in properly sealing joints and penetrations in hazardous areas, inadequate identification and protection of the fire alarm control panel circuit breaker, failure to maintain smoke barriers and smoke barrier doors, and issues with fire alarm system installation.