Pin Oaks Living Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1), in a review of five sampled residents, was free from misappropriation of medications when Registered Nurse (RN) A administered gabapentin (used to treat seizures and nerve pain) instead of the scheduled hydrocodone-acetaminophen (narcotic pain medication used for moderate to severe pain) to the resident. RN A documented he/she administered hydrocodone-acetaminophen on the resident's Medication Administration Record (MAR) and narcotic log, but RN A administered a gabapentin, not hydrocodone-acetaminophen as ordered. The facility census was 87. On 06/16/26 at 1:50 P.M., the Administrator was notified of the past noncompliance which occurred on 05/20/26. On 05/20/26, the Director of Nursing (DON) became aware RN A misappropriated Resident #1's hydrocodone-acetaminophen. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for surgical wound care for one resident (Resident #11), of nine sampled residents. The facility failed to change the resident's wound vacuum assisted closure (vac) dressing (a specialized sealed foam bandage connected to a portable pump that applies gentle, constant suction to the wound) biweekly per the physician's order. As a result, the wound vac sponge adhered to the wound bed and the sternum (breastbone) requiring surgery for urgent wound debridement (the process of removing dead or damaged tissue from a wound) and omental flap mobilization and skin grafting (a reconstructive surgery technique used to cover large, complex or infected tissue defects, particularly on the chest wall using fatty tissue from the abdomen) for final wound closure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of four residents (Resident #2, #3, #4 and #1) in a review of 10 sampled residents to answer call lights and check and change residents in a timely manner. Resident #2, normally continent of bowel and bladder, and requiring staff assistance to use the bathroom, turned on his/her call light and requested staff assist him/her out of bed as he/she needed to use the bathroom. Staff did not respond for three hours, and the resident was incontinent of bladder and bowel. The resident laid in urine and feces. The resident said staff not responding timely to his/her needs made him/her very upset and his/her feelings were hurt when staff treated him/her this way, and his/her skin was irritated and burned from being left soiled. [...]

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon the grievances and recommendations of the Resident Council, concerning issues of resident care and quality of life in the facility, and failed to provide the resident council with responses and actions taken regarding their concerns. The facility census was 89. During an interview on 1/12/26 at 10:00 A.M. the administrator said the facility did not have a policy regarding Resident Council meetings and facility response to the meetings, but she would expect for the facility to follow the regulatory requirements. Review of the Resident Council Minutes, dated 11/17/25, showed the following:-Seven residents attended the meeting;-Resident Council President: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice when staff failed to complete an assessment and documentation or obtain physician orders for treatment related to a fall with injury for one additional sampled resident, (Resident #10) in a review of 11 sampled residents. The facility census was 88. Review of the undated facility policy, Resident Condition Change, showed the following:-Purpose: To observe, record and report any change to the attending physician so that proper treatment can be implemented;-After a resident falls, injuries or changes in physical or mental function, monitor the following: -a. Observe for lacerations. If present, clean and apply dry, sterile dressing or dressing of physician's choice. Note size, depth and amount of bleeding or drainage;-b. [...]

Inspectors wroteBased on observation and interview, the facility failed to routinely post daily staffing sheets and accurately post the number of hours worked by the staff who provided care. The facility census was 89. During an email correspondence dated 1/13/26 12:12 P.M. the administrator said the facility did not have a facility policy specific to posted staffing, but she would expect the facility to follow the regulatory requirements for posted staffing. 1. Observation on 1/7/26 at 3:00 P.M. showed a plastic sleeve attached to a wall at the entrance of the facility. Facility staff verified this was where posted staffing was displayed for the public to view. The plastic sleeve was empty. 2. Review of the posted daily staffing sheet provided by the Director of Nurses (DON), dated 1/1/26, showed the following:-Registered Nurse (RN): 2 worked day shift and hours worked were 24;-RN: [...]

Inspectors wroteBased on observation, interview, and review of the Director of Nursing's (DONs) job description, the facility failed to ensure the DON served full time as DON and did not serve as charge nurse when the facility had an average daily occupancy of over 60 residents. This failure had the potential to affect the completion of nursing administration duties, including (but not limited to) staff training, quality improvement activities, and incident management for all 71 facility residents. The facility census is 71.

Inspectors wrote2. Review of R49's undated Face Sheet, found in the EMR under the Summary tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included depression, history of hallucinations, and anxiety. Review of R49's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The assessment indicated R49 did not exhibit any behaviors or signs and symptoms of depression during the assessment reference period. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure one medication cart observed out of five medications carts was locked when left unattended. The facility further failed to ensure 18 cards of controlled medications were stored in a double lock manner. Lastly, the facility failed to ensure one medication room observed out of three medications rooms was locked when left unattended. This had the potential for residents, staff, and visitors to access the medications for possible misappropriation. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the failed to ensure infection control was maintained during medication administration, failed to ensure oxygen tubing was dated to ensure potential respiratory infection was prevented, and failed to ensure hand hygiene was completed during wound care. This affected four of 24 (Residents (R) 39, R53, R48, and R64) residents. This had the potential for a potential transmission of infection. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one resident (Resident (R)375) observed out of a total sample of 24 residents had an assessment and an order for self-administration of medications. These failures placed R375 at risk for medication errors, overdose, or misappropriation of medications. The facility census was 71.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure code status/advance directives would be honored when the facility failed to obtain a physician's signature or resident/responsible party signature for code status or advance directive paperwork for two residents (R375 and R48) of five residents reviewed for code status out of a total sample of 24 residents. The facility census was 71.

Inspectors wroteBased on interview and record review, the facility failed to properly notify residents of potential non-coverage and beneficiary financial liability for two of three residents (Resident (R)225 and R227) reviewed for beneficiary notification out of a total sample of 24 residents. This had the potential to place undue financial liability on residents without their knowledge. The facility census was 71.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure one resident (Resident (R) R25) out of three residents reviewed for abuse was free from resident to resident verbal abuse. R25 was verbally abused by R49. This failure created the potential for further resident to resident abuse and for R25 to experience psychosocial harm related to the abuse. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to ensure timely reporting of allegations of abuse related to three (Residents (R) R22, R25 and R49) out of a total of three residents reviewed for abuse. R22 reported an allegation of staff to resident abuse and R25 was verbally abused by another resident (R49) and neither incident was timely reported to the State Agency (SA), Ombudsman or local law enforcement. This failure created the potential for these and other residents to experience potential further abuse. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure a thorough investigation was completed related to an incident of resident-to-resident verbal abuse involving two (Residents (R )25 and R49) out of a total of three residents reviewed for abuse. This failure created the potential for R25 and other residents to experience further abuse. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure three residents (R9, R48, and R53) of a total of 24 residents reviewed had comprehensive care plans in place to address all of their needs. R9 did not have a care plan with interventions to prevent the resident from experiencing another coffee burn. R48 did not have a care plan in place to address his behaviors or the administration of his psychotropic medications and R53 did not have a care plan in place to address the administration of her oxygen. This failure created the potential for comprehensive care to not be provided for the residents. The facility census was 71.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a final discharge summary was completed upon discharge for one resident (Resident (R) 17) of three residents reviewed for discharge out of a total sample of 24 residents. This deficient practice had the potential to contribute to a lack of continuity of care and lack of necessary treatment and services. The facility census was 71.

Inspectors wroteBased on facility policy review, observation, record review, and interviews, the facility failed to implement their scheduled activities programs for residents. The facility also failed to ensure one (Resident (R)9) of two residents reviewed for activities was provided with a consistent activity program to meet their needs. The resident was not offered activities based on assessment of her activity preferences. This failure created the potential for the resident to experience isolation related to lack of participation in facility activities. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on facility policy review, review of Broda chair instructions, observation, record review, and interview, the facility failed to ensure one resident (R9) of two residents reviewed for pressure sores was provided with adequate care and treatment to prevent skin breakdown. This failure created the potential for the resident to experience further skin breakdown. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were free from potential accident and hazards during smoking for one of one (Resident (R) 67) reviewed for safe environment out of a sample of 24 residents. This had the potential to place residents at risk of injury from a potential fire. The facility census was 71.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure comprehensive dialysis services were provided for one resident (R22) out of a total of one resident reviewed for dialysis. There were no orders in place related to the care and maintenance of the resident's intravenous (IV) dialysis catheter. This failure created the potential for R22 to receive incomplete and inconsistent care of her dialysis catheter. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure two residents (R9 and R53) of a total of nine residents reviewed for accidents was appropriately assessed for the use of side rails on their beds. The facility further failed to ensure both residents had an informed consent for the use of rails on their beds. This failure created the potential for the residents to be injured related to use of potentially unnecessary side rails installed and in use on their beds. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure the physical safety of bed rails for two (Residents (R)9 and R53) of a total of nine residents reviewed for accidents. Bed rails on both residents' beds were observed to be loose. This failure created the potential for the residents to be injured by improperly applied and unmaintained bed rails. A total of 24 residents were reviewed in the sample. The facility census was 71.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from misappropriation of property when 40 tablets of oxycodone/acetaminophen (narcotic pain medication used to treat moderate to severe pain) and five tablets of gabapentin (used to treat nerve pain) were determined missing for one resident (Resident #1), when in the possession of facility staff. A sample of seven residents was selected for review. The facility census was 68. Review of the facility's Abuse Prohibition Protocol, undated, showed the following: -It is the policy of this facility that reports of misappropriation of property are promptly investigated; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure narcotic counts were completed to ensure any missing doses could be readily detected, failed to label medications, and failed to store medications in a safe and effective manner. Licensed staff failed to complete on-coming and off-going controlled drug counts to verify the correct count of narcotics for one resident (Resident #1). Licensed staff also failed to follow the facility policy when accepting medications that were brought from home for the resident to ensure the medications were examined and positively identified by the pharmacist and approved for the resident's use. The facility census was 68. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated three residents (Residents #7, #8 and #9), in a review of ten sampled residents, with dignity and respect when they refused to provide assistance and verbalized rude and disrespectful comments to the residents. The facility census was 71. Review of the facility undated policy Resident's Rights showed the following: -Long-term care residents have a right to care which maintains or enhances the quality of life; -Residents should be treated with consideration and respect, with full recognition of their dignity and individuality. Review of the undated facility admission packet showed the following: -As a nursing home resident, you have the right to privacy and respect; -You shall be treated with consideration, respect and full recognition of your dignity and individuality; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain exhaust vents, lighting, heating/ventilation units, walls, ceilings, and flooring in good repair and free of a buildup of debris. The facility census was 67. Observation and interview on 2/21/23 at 9:34 A.M. in occupied resident room [ROOM NUMBER] showed the brown wall paint was marred with exposed drywall behind the bed closest to the room door. A large patch of drywall compound was visible in the sink vanity area next to the mirror. Maintenance Staff C said the old soap dispenser had been removed and relocated. The area needed to be finished and painted. Observation on 2/21/23 at 9:42 A.M. in occupied resident room [ROOM NUMBER], showed the brown wall paint was marred behind the bed closest to the door. Observation on 2/21/23 at 9:47 A.M. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain good personal hygiene for three residents (Resident #9, #32, and #370), who required assistance to perform their activities of daily living, in a review of 18 sampled residents. The facility census was 67. Review of the facility's undated policy, Bath (Shower), showed the following: -The purpose was to maintain skin integrity, comfort and cleanliness; -Wash face, upper extremities and body, lower extremities and feet, perineal area, and shampoo hair; -Dress resident, comb and style hair. (The facility's policy did not identify when staff were to bathe a resident.) Review of the facility's undated policy, Shaving the Resident, showed to remove facial hair and improve the resident's appearance and morale. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer three residents (Residents #4, #53, and #62), in a review of 18 sampled residents; failed to utilize a gait belt when repositioning two residents (Residents #6 and #62); and failed to safely transport one resident (Resident #4) in a wheelchair. The facility census was 67. Review of the facility's undated policy for wheelchair use showed footrests should be lowered and the resident's feet placed on them if used. The resident's feet and legs should be placed in good body alignment. Review of an undated facility policy for gait belt use showed the following: -Purpose: To provide better control and balance while assisting resident with ambulation and transfer. -Resident transfers: -Assist resident to a sitting position; -Apply belt to resident's waist; tighten to fit snugly with the buckle at the side; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement respiratory and oxygen interventions and monitoring and maintain continuous positive airway pressure (CPAP; machine that uses mild air pressure to keep breathing airways open while you sleep) equipment according to the facility's policy for four residents (Resident #1, #4, #9 and #24), in a review of 18 sampled residents. The facility census was 67. Review of the facility's undated policy, Cleaning Guidelines-Oxygen Equipment, showed tubing, masks, and cannulas used with oxygen therapy should be replaced monthly and as needed (PRN), and marked with date and initials. Review of the facility's Oxygen Administration policy, undated, showed the following: -A reserve oxygen tank should be available to provide continuity of care; -Label reusable humidifiers with date and time opened; [...]

Inspectors wroteBased on observation and interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during storage, preparation, and distribution. The facility census was 67. Observation on 02/21/23 of the noon meal preparation and service showed the following: -At 9:22 A.M., the Dietary Manager and Dietary Aide B prepared food for the noon meal. Both staff had hair hanging out of the sides of their hairnets; -At 10:18 A.M., the Dietary Manager helped prepare the lunch meal, and did not have the top of his/her hair covered with a hairnet; -At 10:22 A.M., the Dietary Manager made cornbread and the sides and top of his/her hair were not covered with a hairnet; -At 11:33 A.M., the Dietary Manager cut corn bread and the sides and top of his/her hair was not covered with a hairnet; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands and changed their gloves after each direct resident contact and when indicated by facility policy during personal care for four residents (Residents #21, #24, #30, and #44), in a review of 18 sampled residents, and for one additional resident (Resident #3). The facility failed to ensure sanitary practices when handling wound care supplies during and after wound care for one resident (Resident #120), and failed to ensure proper infection control practices were utilized for respiratory care supplies for two residents (Residents #4 and #370). The facility failed to ensure all procedures were implemented to address prevention, development, and transmission of Tuberculosis (TB) as directed by facility policy. The facility failed to ensure Tuberculin Skin Tests (TST; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for two residents (Residents #4 and #62), in a review of 18 sampled residents. The facility census was 67. Review of facility's undated call light policy showed the following: -Purpose: To respond promptly to resident's call for assistance; -When providing care to residents, be sure to position the call light conveniently for the resident's use; -Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate one resident's (Resident #41's) wheelchair as a restraint, in a review of 18 sampled residents. The resident's wheelchair was positioned so the resident's legs were in front of him/her (horizontal with the floor). Staff documented the resident had poor safety awareness and impulsive behavior, and frequently attempted to get out of his/her wheelchair. The facility census was 67. Review of undated facility policy, Physical Restraints, showed the following: -Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one resident (Resident #4), in a review of 18 sampled residents. Staff failed to administer three doses of ordered medication and to obtain laboratory testing as ordered following the resident's return from the hospital. The facility census was 67. Review of the undated facility policy, Physician Orders, showed the following: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Physician orders must be reviewed and renewed. 1. Review of Resident #4's Face Sheet showed the resident's diagnoses included hypokalemia (a blood level that is below normal in potassium, which can result in fatigue, muscle cramps, and abnormal heart rhythms). Review of the resident's progress note, dated 2/1/23 at 2:40 A.M., showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #120), in a review of 18 sampled residents, received necessary care/treatments to prevent and/or heal pressure ulcers. Staff failed to ensure the resident, who had a pressure ulcer on his/her left heel, had heel protectors on while he/she was in bed. The facility census was 67. Review of facility's undated policy, Pressure Ulcer Care and Prevention, showed the following: -The purpose was to prevent and treat further breakdown of pressure ulcers; -The nurse was responsible for carrying out the treatment as ordered by the attending physician and for implementing measures to prevent pressure ulcers; -Staff should use heel protectors if needed. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide proper care to a urinary catheter (a tube inserted in to the bladder to excrete urine out of the body) for one resident (Resident #120), in a review of 18 sampled residents, by failing to keep the catheter drainage bag and catheter tubing from touching the floor. The facility identified two residents with a urinary catheter. The facility census was 67. Review of the facility's undated policy, Catheter/Emptying a Urinary Drainage Bag, showed to keep the drainage bag and tubing off of the floor at all times to prevent contamination and damage. 1. Review of Resident #120's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by facility staff, dated 8/22/22, showed he/she had a urinary catheter. Review of the resident's physician's orders, dated 2/9/23, showed the resident had a urinary catheter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement trauma informed care for one resident (Resident #307), in a review of 18 sampled residents. The resident had a diagnosis of post traumatic stress disorder with a history suicidal ideations. The facility census was 67. Review of Resident #307's Preadmission Screening and Resident Review (PASRR) II (evaluation on a resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms), dated 1/30/21, showed the following: -The resident was admitted in 1993 in a hospital with suicidal gesture, cut wrists, inpatient for a month; -The resident's parent passed away from brain aneurysm (weakness in a blood vessel in the brain that can leak or rupture, causing life-threatening bleeding) from the motor vehicle accident when the resident was 14 or l5 years old; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation to show a Notice of Medicare Provider Non-Coverage (NOMNC; from CMS-10123) and a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents (Residents #3 and #9), who remained in the facility upon discharge from Medicare A services. The facility census was 67. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The NOMNC is issued when all covered Medicare services end for coverage reasons; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer/discharge to the resident and/or the resident representative when five residents (Residents #4, #9, #21, #62, and #370) in a review of eighteen sampled residents were transferred to the hospital. The facility census was 67. During interview on 2/28/23 at 2:00 P.M., the administrator said there was no specific policy for written notices of transfer/discharge to the residents and/or the resident representatives, but was aware they were required. 1. Review of Resident #21's face sheet showed the resident was his/her own responsible party. Review of the resident's nurse's notes, dated 2/3/23 at 4:45 P.M , showed the resident was sent to the emergency room for treatment of visual disturbances. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative when the facility initiated a transfer to the hospital for five residents (Residents #4, #9, #21, #62, and #370), in a review of 18 sampled residents. The facility census was 67. Review of the facility's undated policy, Bed Hold Guidelines, showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines; -The notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to act promptly upon the grievances and recommendations of the resident council concerning resident care in the facility; and failed to provide the resident council with responses, actions and rationale taken regarding their concerns. The facility census was 76. 1. Review of the facility's policy, Resident Council, dated March 2012, showed the following: -The resident population will elect a resident council annually in the facility. Monthly meetings will be held with minutes of the meetings documented. Recommendations for changes by the council will be given to the administrator who will evaluate the recommendations. The resident council serves as a liaison between the employees, residents and others who interface with the facility; -Concerns and needs are addressed as voiced by members of the council; [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the floors and walls in good repair, and failed to maintain comfortable temperatures in the facility. The census was 76. 1. Observation on 8/6/19 at 3:34 P.M. showed black marls on the bathroom floor and around the toilet in the bathroom for room [ROOM NUMBER]. The soap dispenser on the wall by the sink had been removed leaving holes in the wall from where it had been attached. Observation on 8/6/19 at 10:45 A.M. showed the wall behind the bed in room [ROOM NUMBER] was marred with multiple areas of chipped and missing paint. Observations on from 8/6/19 to 08/09/19 showed the following: -Multiple areas of chipped paint on the wall behind bed 1 in room [ROOM NUMBER]; -Multiple areas of chipped paint on the wall behind bed 2 in room [ROOM NUMBER]; -Multiple areas of chipped paint on the wall behind bed 2 in room [ROOM NUMBER]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice and physician orders for three residents (Residents #11, #31, and #54), in a review of 22 sampled residents. The facility failed to provide one resident (Resident #54) with honey thickened (liquids thickened to honey consistency) water in his/her room; failed to ensure oxygen administration was set at prescribed level as physician ordered for three residents (Residents #54, #31, and #11). The facility census was 76. 1. Review of the facility policy Physician Orders, dated March 2015, showed the following: -Current list of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Orders must be signed by the physician and dated when such order was signed; -Physician orders must be reviewed and renewed; -Oxygen orders: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided six residents (Residents #11, #28, #47, #54, #55, and #65), in a review of 22 sampled residents, and two additional residents (Residents #8 and #66), who were unable to perform their own activities of daily living, the necessary care and services to maintain good personal and oral hygiene. The facility census was 76. 1. Review of the facility's policy, Perineal Care, dated March 2015, showed the following: -Purpose: to cleanse the perineum and to prevent infection and odor; -Female perineal care: Put on disposable gloves. Wet washcloth and make a mitt with it. Apply soap lightly, use one gloved hand to stabilize and separate the labia. With the other hand, wash from front to back, rinse and pat dry; -Male perineal care: Put on disposable gloves. Wet washcloth and make a mitt with it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oversight to prevent one additional resident (Resident #61) from wandering outside the facility in a wheelchair. The resident left the facility through an unlocked and unalarmed door. The facility failed to safely transfer three residents (Residents #24, #54 and #65), in a review of 22 sampled residents. The facility census was 76. 1. Review of the facility policy Elopement-Missing Resident from the Nursing Guidelines Manual, dated March 2015, showed the guidelines discussed a resident missing, who to notify, thorough search, notifying law enforcement, and when located, to assess for injuries. The policy did not address assessing residents for elopement/wandering risk and prevention measures. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet residents' needs for seven residents (Residents #11, #17, #24, #31, #33, #54, and #65), in a review of 22 sampled residents, and three additional residents (Residents #8, #38, and #100). The facility census was 76. 1. During interview on 8/9/19 at 2:30 P.M., the director of nursing said the facility had no policy regarding facility staffing. 2. During interview with the facility's resident council on 8/6/19/19 at 1:24 P.M. showed the following: -Residents #33 said he/she has had to wait 30 to 40 minutes for staff to answer his/her call light and doesn't feel there are enough staff to get the showers done. He/she feels all three shifts need more help; -Residents #100 said he/she had to wait up to an hour for staff assistance; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff served food at an appetizing temperature. The facility census was 76. 1. Review of the facility policy, Food Temperatures, dated May 2015, showed hot food should be at least 120 degrees Fahrenheit (F) when served to the resident. 2. During interview on 8/6/19 at 1:37 P.M., Resident #5 said the food served was always cold. The dietary staff brought a cart of trays to the dining room (located by the 400 and 500 hall) for each meal. Staff did not get those trays served for over 15 to 20 minutes. When staff finally got around to passing out the meal trays, the food was cold. 3. Observation on 8/7/19 at 1:14 P.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to offer residents a daily bedtime snack. The census was 76. During group interview on 8/6/19 at 1:24 P.M., the residents said the following: -Resident #2 said he/she had to get bedtime snacks at the nurses station. Staff do not bring bedtime snacks to the residents; -Resident #5 said staff bring a bowl of snacks to the nurses station but they do not normally bring the snacks to the residents' rooms. He/she would like a snack at night; -Resident #4 said staff will eventually bring a snack if he/she asks for it. Observation on 8/7/19 at 8:00 A.M., showed a blue bowl sat on the nurses station containing various snacks. Observation on 8/8/19 at 5:30 A.M., showed a blue bowl sat on the nurses station containing various snacks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standards of practice during personal care for four residents (Residents #28, #37, #47 and #54), in a review of 22 sampled residents Facility staff failed to transport clean linens in such a way as to prevent cross-contamination. The facility census was 76. 1. Review of the facility's policy, Gloves, dated March 2015, showed the following: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, maintain, and update a plan of care consistent with residents' specific conditions, needs, and risks based on their comprehensive assessment for one resident (Resident #65), in a of 22 sampled residents. The facility census was 76. 1. Review of the facility policy Care Plan Comprehensive, dated March 2015, showed the following: -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff); Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment; [...]

Inspectors wroteBased on observation and interview, the facility failed to prominently post the results of the most recent standard survey, any deficiencies resulting from subsequent complaint investigations, and any plans of correction in a place readily accessible to residents, family members, and legal representatives. The facility failed to post a notice of the availability of such reports in areas that are prominent and accessible to the public. The facility also failed to have reports from any surveys, certifications, and complaint investigations during the three preceding years, and any corresponding plans of correction available for individuals to review upon request. The facility census was 76. Observations on 8/6/19 through 8/7/19 showed a black notebook on the small round table by the front door to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and resident representatives of their bed hold policy at the time of transfer to the hospital for three residents (Residents #47, #59, and #68), in a review of 22 sampled residents. The facility census was 76. 1. Review of the facility's undated policy, Bed Hold Policy Notification, showed staff will give this policy to the resident or resident representative at the time of admission, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave. 2. Review of Resident #47's census report showed the resident was transferred to the hospital on 4/20/19. [...]