Tierra Pines Center

Inspectors wroteBased on record review and staff interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for eight (#81, #7, #10, #63, 86,#16, #266 and #43) of 12 residents reviewed for PASARRs.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure proper monitoring of sanitation solution for the dish machine in 1 of 1 facility kitchens. Findings Included: During a kitchen tour on 01/27/2025 at 9:50 a.m., Staff F, Dietary Aide, stated the dish machine is a low temp machine. He stated he does not normally record the temps or the sanitizing parameters for the machine. He pointed at the Certified Dietary Manager (CDM) and stated he (CDM) fills out the log. Staff F, Dietary Aide, was not sure what the rinse cycle water temp needed to be at. Staff F, Dietary Aide started a wash cycle and checked the sanitation level. The test strip stayed white during the testing, showing there was no sanitation. The sanitation bucket which was located below the dish machine was noted empty. Review of the Dish Machine Temp Log revealed and entry for Breakfast on 01/27/2025. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure recommendations from the Preadmission Screening and Resident Review (PASRR) Level II were incorporated into the care plan for one Resident (#46) out of eight residents sampled.

Inspectors wroteBased on observation interview and record review, the facility failed to provide or assist with shaving facial hair for two residents (#72 and #78) of three reviewed for Activities of Daily Living (ADL) care. Findings Included: 1. During an interview and observation on 1/27/25 at 1:35 P.M. Resident #72 was lying in bed wearing a hospital gown, his facial hair on his neck and the sides of his face were approximately ½ inch in length and appeared unkept. Resident #72 said he would like the hair under his chin and neck to be shaved and staff have not offered to assist him. During an interview and observation on 1/28/25 at 11:15 A.M. Resident # 72 said he does not like the hair on his face and neck, when I get a shower it [facial hair] softens up. Resident #72's unkept facial hair remained unchanged on 1/29 and 1/30. During an interview on 1/30/25 a 2:34 P.M. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to stop bleeding, protect wounds from infection, and promote healing for one resident (#73) of one reviewed for non-pressure related wound care and failed to follow physician orders related to wound care for one resident (#4) out of 6 residents sampled.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain equipment as evidenced by one of two laundry washers not working; two of three laundry dryers not working; one of one unclean gas stove; one of one exhaust hood with peeling paint over stove; and a leaky garbage disposal.

Inspectors wroteBased on observation, staff interview, and facility record review, the facility failed to ensure resident spaces and equipment were clean and maintained related to: 1. Twelve of thirty-three wheelchairs observed with cracked and torn armrests; 2. Three of seven resident room over the bed tables observed with peeled surfaces, and uneven surfaces; and 3. One resident room, room [ROOM NUMBER] observed with heavy water saturation damage with biogrowth on both the door wall and the ceiling. Observations revealed the above concerns in four of four halls during two of two days observed, on (10/30/2023 and 10/31/2023).

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to ensure the kitchen was maintained in a sanitary manner as evidence by: 1. the dish washing machine was not receiving sanitizer via the liquid sanitizer delivery system for three wash cycles observed and washing temperatures were not meeting the required temperature; 2. one of one walk in freezers had a large amount of ice buildup; and 3. black bio growth built up on a wall near and behind the dish washing machine, for two days (12/5/2022 and 12/6/2022) of four day observed.

Inspectors wroteBased on interviews and record review the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#363, #362 and #361) of three residents sampled.

Inspectors wrote3. On 12/6/22 at 8:41 a.m. an observation was made of Staff L, Registered Nurse (RN) during medication administration. The nurse was preparing medication for Resident #36. She took the resident's blood pressure, then proceeded to remove six pills from the blister pack directly into her ungloved hand. She then placed the pills from her hand into a medication cup and administered them to Resident #36. Staff L then moved on to prepare medication to be administered to Resident #15. Prior to retrieving the resident's medication Staff L took Resident #15's blood pressure. The nurse used the same blood pressure cuff used on the previous resident without sanitizing it in between uses. On 12/6/22 at 9:03 a.m. an interview was conducted with Staff L, RN. She stated the pills should be popped from the blister back straight into a medication cup and she knows she shouldn't handle them. [...]

Inspectors wrote2. On 11/6/2022 at 9:20 a.m. an observation was made in room [ROOM NUMBER]. The A bed's call light was observed missing from the call light system attached to the wall inside room [ROOM NUMBER]. On 11/6/2022 at 9:30 a.m. an interview was conducted with the resident in the A bed. The Resident said she never had a call light in her room and she is independent, so she really doesn't need assistance from the staff. The Resident in the B bed overheard the conversation and said she would usually put the call light on if [Resident A bed] needed assistance from the staff. On 12/6/2022 at 10:00 a.m. an interview was conducted with Staff A, CNA. Staff A said room [ROOM NUMBER] has always had one call light in the room. Staff A said there was a padded call light in the room at first and then they changed that call light out for the regular call light that is in the room now. [...]

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure a trauma-based care plan related to a Post-Traumatic Stress Disorder (PTSD) diagnosis was implemented for two residents (Resident #73 and #58) of two residents sampled.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide respiratory care consistent with professional standards of practice related to not notifying the physician of an episode of respiratory distress and did not following physician oxygen orders for one resident (#95) out of two residents reviewed for oxygen for two out of three observations made of Resident #95.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure staff were qualified with competencies related to trauma-based care and treatment for Post-Traumatic Stress Disorder (PTSD) diagnosis for two residents ( #73 and #58) of two residents sampled.

Inspectors wroteBased on record review and interviews the facility did not ensure the attending physician provided rationale for disagreeing with the pharmacist recommendations as part of the Drug Regimen Review for two residents (#94 and #43) out of five residents reviewed for unnecessary medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents were referred to the appropriate state designated authority when it became evident after admission that the resident had a mental illness or related condition for 1 of 4 (#77) residents sampled for preadmission Screening and Resident Review.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to implement the care plans for two of thirty-two sampled residents (Resident #87) related to the use of an adult monitoring device and contractures (Resident #60) out of the sampled thirty-two residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that 4 vials of Lorazepam 2mg/ML, a Schedule IV medication, were stored in a permanently affixed compartment, separate from other medications in a locked refrigerator for one of two medication storage rooms (First Floor Medication Storage Room).