Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to and the facility must promote and facilitate resident
self-determination through support of resident choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure a system
to accommodate resident choice for rising in the morning for two of 18 sampled residents
(Residents #32, and #52) and three additional residents (Residents #19, #26, and #63).
Facility staff began to get residents out of bed at 5:00 A.M. or earlier based on a list
of residents and their level of required assistance, rather than preferences. The facility
census was 82.
1. During interview on 11/29/18 at 3:17 P.M. the director of nursing (DON) said the
facility did not have a policy for early morning awakening/get up times.
2. Review of the facility’s undated policy titled Resident Rights, showed residents shall
not have their personal lives regulated or controlled beyond reasonable adherence to meal
schedules or other written policies which may be necessary for the orderly management of
the facility and the personal safety of the Residents.
3. Review of the POS [REDACTED]
-Allow me to have dignity;
-See my personal habits as important;
-See me as a real person.
4. Review of Resident #63’s annual Minimum Data Set (MDS), a federally mandated assessment
tool required to be completed by facility staff, dated 5/14/18, showed the following:
-Cognition was moderately impaired;
-Very important to choose his/her own bedtime;
-Extensive assistance of two staff for bed mobility, transfers, and dressing;
-Upper extremity impairment on one side;
-Mobility devices include a wheelchair;
-At risk for pressure ulcers.
Review of the resident’s care plan, dated 5/23/18 with last review 11/15/18, showed the
following:
-I have a physical functioning deficit related to self-care impairment and mobility
impairment;
-Encourage choices with care. Likes to get up around 6:00 A.M.
Observation on 11/28/18 showed the following:
-At 5:30 A.M., the resident sat in a wheelchair at the North hall nurse’s station with
head tilted down and chin touching his/her chest, dressed for the day with eyes closed;
-At 5:55 A.M., the resident continued to sit in a wheelchair at the nurse’s station with
his/her eyes closed;
-At 6:22 A.M., the resident continued to sit in a wheelchair at the nurse’s station with
his/her eyes closed;
-At 6:52 A.M., housekeeping staff was observed placing a pillow under the resident’s feet
and legs on his/her footrest;
-At 7:42 A.M., the resident sat in the dining room with head tilted down and chin touching
chest with eyes closed and drinks in front of him/her. The resident had not received
his/her meal tray.
During interview on 11/29/18 at 10:44 A.M., the resident said it depended on his/her plans
for the day as to what time he/she wanted to get up but his/her preference was 5:30 A.M.
to 6:00 A.M. and to stay in his/her room.
4. Review of Resident #52’s admission MDS, dated [DATE], showed the following:
-Cognition was severely impaired;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
-Somewhat important to choose his/her own bedtime;
-Extensive assistance of one staff for bed mobility, transfers and dressing;
-Mobility device includes a wheelchair;
-At risk for pressure ulcers.
Review of the resident’s current medical record, including the care plan, showed no
documentation of any assessment regarding preferred or usual waking time.
Observation on 11/28/18 showed the following:
-At 5:30 A.M., the resident sat in a wheelchair at the North hall nurse’s station dressed
for the day with eyes closed;
-At 5:55 A.M., the resident continued to sit in a wheelchair at the nurse’s station with
his/her eyes closed;
-At 6:00 A.M., licensed practical nurse (LPN) F prepared the resident’s medications and
spoke the resident’s name ten times and rubbed his/her arms to wake the resident up to
take his/her medications. The resident did not open his/her eyes. LPN F placed a glass of
water up to the resident’s lips and gave him/her a drink of water to get him/her to open
his/her eyes. LPN F then took the resident into the staff break room to remove the old
[MEDICATION NAME] and put on a new [MEDICATION NAME];
-At 6:22 A.M., the resident continued to sit in a wheelchair at the nurse’s station with
his/her eyes closed;
-At 7:42 A.M., the resident sat in the dining room with juice and milk in front of
him/her. The resident had not received his/her meal tray.
During interview on 11/29/18 at 10:49 A.M., the resident said he/she didn’t like getting
up and would like to sleep in; 7:00 A.M. was about his/her time to get up.
5. Review of Resident #19’s annual MDS, dated [DATE], showed the following:
-Cognition was intact;
-Highly impaired hearing;
-Staff completed the daily and activity preference section;
-Limited assistance of one staff for bed mobility and transfers;
-Extensive assistance of one staff for dressing;
-Mobility devices include a walker and wheelchair;
-At risk for pressure ulcers.
Review of the resident’s current medical record, including the care plan, showed no
documentation of any assessment regarding preferred or usual waking time.
Observation on 11/28/18 showed the following:
-At 5:30 A.M., the resident sat in a wheelchair at the North hall nurse’s station dressed
for the day and did not respond when spoken to;
-At 5:44 A.M., the resident sat in a wheelchair with his/her head tilted down and chin
touching his/her chest and eyes closed;
-At 5:55 A.M., the resident remained in his/her wheelchair with eyes closed;
-At 6:22 A.M., the resident remained sitting in his/her wheelchair in front of nurse’s
station with eyes closed.
5. Review of Resident #32’s significant change MDS dated [DATE], showed the following:
-Cognition was severely impaired;
-Very important to choose his/her own bedtime;
-Extensive assistance of two or more staff for bed mobility and transfers;
-Dependent on one staff for dressing;
-Impairment on one side of upper and lower extremity;
-Mobility device includes a wheelchair;
-At risk for pressure ulcers.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
Review of the resident’s care plan, dated 9/27/17 with last review 10/16/18, showed the
following:
-I have a physical functioning deficit related to self-care impairment;
-Has no preference when to get up.
Observation on 11/28/18 showed the following:
-At 5:30 A.M., the resident sat in a wheelchair at the North hall nurse’s station dressed
for the day and did not respond when spoken to;
-At 6:22 A.M., the resident continued to sit in a wheelchair at the nurse’s station with
his/her eyes closed.
During interview on 11/29/18 at 10:56 A.M., the resident said he/she would like to wake up
at 8:00 A.M.
6. Review of Resident #26’s significant change MDS, dated [DATE], showed the following:
-Cognition was severely impaired;
-Very important to choose his/her own bedtime;
-Extensive assistance of two staff for bed mobility, transfers, and dressing;
-Mobility devices include a wheelchair;
-At risk for pressure ulcers.
Review of the resident’s current medical record, including the care plan, showed no
documentation of any assessment regarding preferred or usual waking time.
Observation on 11/28/18 showed the following:
-At 5:55 A.M., the resident lay in a Broda (tilt-in-space positioning) chair reclining
almost flat at the nurse’s station with his/her eyes closed;
-At 6:19 A.M., a staff member touched the resident’s left cheek to examine a spot and the
resident’s eyes remained closed;
-At 6:22 A.M., the resident remained reclined in the Broda chair with eyes closed;
-At 7:42 A.M., the resident lay in Broda chair at a 45 degree angle with eyes closed at
the dining room table.
7. During interview on 11/28/18 at 6:55 A.M. Certified Nurse Aide (CNA) H said there was a
list with about 13 residents that on a normal day staff start getting up around 4:00 A.M.
because they are two people assist and staff do it to help the day shift.
During interview on 11/28/18 at 6:07 A.M., CNA H said the night shift get Residents #26
and #52 up to help day shift. Resident #52 is a stand up lift and Resident #26 is a Hoyer
(mechanical lift) lift.
During interview on 11/28/18 at 6:24 A.M., CNA I said the following:
-Resident #32 gets up due to he/she is on the get up list and is paralyzed on left side;
-Resident #26 gets up due to he/she is on the get up list;
-The staff do bed checks at 4:00 A.M. and start getting residents up at 5:00 A.M.
During interview on 11/29/18 at 9:35 A.M., Licensed Practical Nurse (LPN) J said the
following:
-The get up list depends on the resident’s skin condition. If a resident has a skin
problem they stay in bed and are the last ones to get up;
-The charge nurses determine what residents are on the list;
-Staff are to start getting residents up at 5:00 A.M., but he/she does not work on the
night shift so he/she does not know when they actually start;
-Resident #63 likes to stay in bed until after breakfast;
-He/she and the night charge nurse make the list and they discuss with each other before
changing the list;
-He/she does not know why Resident #63 was on the get up list;
-Resident #26 is on the list due to he/she hollers, so staff get him/her up whether he/she
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0561

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
is hollering or not.
During interview on 11/29/18 at 9:29 A.M., the Social Service director said the staff fill
in the section on the MDS for likes and dislikes regarding get up and bedtime from
information they gather from the residents and or families.
During interview on 11/29/18 at 4:02 P.M., the DON said the following:
-She would expect staff to check on the residents every two hours and if they want to stay
in bed it should be their choice;
-Staff make the list with residents that need help getting up with one or two assist;
-Residents that require a lift are up first;
-Staff know the residents wake up preference due to a lot of the staff have worked at the
facility a long time and worked with the same residents often. It is routine at shift
change to get the residents up;
-There was no documentation of a resident’s get up preference;
-She was not familiar with a get up list;
-Staff should start getting residents up at 5:00 A.M.
During interview on 11/29/18 at 4:34 P.M., the administrator said the following:
-He does not expect staff to wake residents to get them up;
-He would not expect staff to wake residents at 4:00 A.M. to get up;
-Department heads evaluate the resident’s or their family for wake up preference on
admission and the MDS staff incorporate the preference on the care plans;
-The list is a guide for the night shift to go and check if the resident wants to get up
for the morning.

F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Immediately tell the resident, the resident’s doctor, and a family member of situations
(injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to immediately
notify one resident’s (Resident #201) in a review of eighteen sampled residents, family
and physician when the resident received a burn from coffee and required treatment. The
facility census was 82.
1. Review of the facility’s Resident Change of Condition Policy, Nursing Guidelines
Manual, dated (MONTH) (YEAR) showed the following:
-Purpose: To observe, record and report any condition change to the attending physician so
that proper treatment can be implemented;
-After all resident falls, injuries or changes in physical or mental function, monitor the
following;
-Have someone stay with the resident while the nurse is calling the attending physician,
if necessary. If you are unable to reach the attending physician or the physician on call,
call the facility medical director for emergency situations;
-Complete an incident, accident or risk management report per facility guidelines;
-Notify resident’s responsible party;
-Notify physician of condition change, need for treatment orders and/or medication order
changes.
2. Review of the Notification of Physician Policy, undated, showed the following:
-RESPONSIBILTY – All licensed staff;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-PURPOSE – To ensure proper and timely notification of physician regarding resident’s
care: Upon admission; upon any identified change of condition; as directed by physician’s
protocol; and when deemed necessary by nursing staff;
-POLICY – Facility will immediately inform the resident; consult with the resident’s
physician; and if known, notify the resident’s legal representative or interested family
member when there is: An accident resulting in injury to the resident and has potential in
requiring physician intervention;
-A need to alter treatment significantly;
-Supervising physician will be available to assist facility in coordinating overall
program of medical care in facility;
-Each facility resident will be under the medical supervision of a Missouri state licensed
physician who’s informed of facility’s emergency medical procedures and is kept informed
of treatments and medications prescribed by any other professional lawfully authorized to
prescribe medications;
-PR[NAME]EDURE – All calls and/or faxes made to physicians regarding resident care will be
documented.
3. Review of Resident #201’s care plan last updated 5/17/18, showed the following:
-Impaired neurological status related to [MEDICAL CONDITION] (disease that affects the
nerve cells in the brain that produce [MEDICATION NAME]. [MEDICAL CONDITION] symptoms
include muscle rigidity, tremors, and changes in speech and gait);
-Will be free of injury daily or will be addressed;
-Assist with Activities of Daily Living (ADLS) and mobility as needed;
-Monitor resident for change in condition;
-Keep family informed of change in condition.
Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/27/18, showed the following:
-[DIAGNOSES REDACTED].
-Short term memory problems;
-Required extensive assist of one staff for bed mobility, dressing and personal hygiene;
-Required extensive assist of two staff for transfers and toileting;
-Required limited assistance of one staff for eating;
-Pain indicators included non-verbal sounds and facial expressions;
-Functional impairment on one side of upper extremity;
-No pressure ulcers, wounds or other skin problems.
Review of the resident’s weekly skin assessment dated [DATE] at 10:23 P.M., showed the
following:
-Assessment completed at 9:30 P.M.;
-New skin issue;
-[MEDICAL CONDITION];
-Resident noted to have area on the left hip that is irregular shaped and looks like was a
water filled blister that popped. Area cleansed and triple antibiotic ointment applied.
Review of the medical record showed no documentation the resident’s physician or family
was notified of the wound to the left hip.
Review of the resident’s physician order [REDACTED].
Review of the resident’s treatment administration record (TAR) dated 1/1/19 through
1/11/19 showed no treatment to the left hip wound.
Observation on 1/11/19 at 5:39 A.M., showed the following:
-Certified Nurse Assistant (CNA) R entered the resident’s room to change him/her from
incontinence;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
-The resident had a dressing on his/her left hip with yellow drainage noted on the
dressing.
During interview on 1/11/19 at 5:39 A.M., CNA R said the following:
-The pads were wet from urine and drainage from a burn on the resident’s leg;
-The burn was from hot coffee.
Review of the resident’s initial and weekly wound documentation dated 1/11/19 showed the
following:
-Observation date 1/9/19 at 1:13 P.M.;
-Recorded 1/11/19 at 1:14 P.M.;
-Description-left hip, blister, new 8.5 x 6.5 centimeters (cm).
During interview on 1/15/19 at 3:16 P.M., housekeeper U said the following:
-He/she worked on 1/5/19;
-Resident #201 was sitting at the dining room table with half cup of coffee in an adaptive
cup;
-While serving another resident he/she noticed Resident #201 had his/her cup upside down
and coffee was flowing out on his/her clothing protector, pants and blanket;
-He/she took the resident to Certified Medication Technician (CMT) T and Licensed
Practical Nurse (LPN) M and told them the resident spilled coffee on him/herself and
his/her pants were wet around 6:15 A.M. – 6:20 A.M.;
-Both staff members immediately turned and said okay.
During interview on 1/11/19 at 1:35 P.M., CMT T said the following:
-He/she worked on 1/5/19;
-Housekeeping staff brought the resident to the nurses from the dining room and reported
the resident had spilled coffee.
During interview on 1/28/19 at 11:16 A.M., LPN M said the following:
-He/she worked day shift on 1/5/19 and 1/6/19;
-He/she doesn’t remember any staff bringing the resident to him/her reporting the resident
had spilled coffee;
-If the burn was reported to him/her, he/she doesn’t remember;
-He/she remembers hearing about the resident’s burn on Sunday (1/6/19) morning from the
night shift nurse, LPN S after he/she had completed the skin assessment on 1/5/19;
-He/she forgot to notify the physician;
-He/she reported the burn to the resident’s family member on Sunday (1/6/19) when he/she
was in the facility;
-He/she did no treatment to the burn 1/10/19 or 1/11/19 as there was no treatment listed
on the TAR and he/she forgot about it.
During interview on 1/11/19 at 10:26 A.M., the resident’s family member said he/she wasn’t
at the facility on 1/6/19. Staff told him/her about the burn on the resident’s left hip on
1/9/19 and said they didn’t know what caused the burn unless the resident had spilled
coffee.
During interview on 1/28/19 at 9:23 A.M., LPN S said the following:
-He/she worked 1/5/19;
-His/her shift started at 6:00 P.M. and all the residents were out of the dining room when
his/her shift started;
-A CNA put the resident to bed and found the irregular shaped wound to his/her left hip
and reported it to him/her;
-He/she thought it looked like a hot liquid spill due to the irregular edges of the wound;

-He/she cleaned the wound with wound cleanser and applied a dry dressing;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
-He/she paged the physician but never got a call back;
-He/she passed the information on the next morning to LPN M that the physician and family
needed to be notified as he/she didn’t get a hold of them;
-He/she should have followed up;
-On 1/6/19 shift report, LPN M reported to him/her that a CNA changed the resident after a
coffee spill on 1/5/19, but there was no pinkness so the CNA did not report it to him/her;

-He/she looked at the burn on 1/6/19 with LPN M and they both agreed that it looked like a
hot liquid burn;
-LPN P/wound nurse was in the facility doing wound measurements and looked at the burn and
measured it;
-LPN P said he/she would call and get an order for [REDACTED].>-Nothing was done to get
a treatment for [REDACTED].
During interview on 1/11/19 at 12:25 P.M. and 1:24 P.M. and 1/29/19 at 1:37 P.M., LPN
P/wound nurse said the following:
-LPN S reported to someone that the resident spilled coffee after supper on 1/5/19;
-He/she was notified of the burn on 1/6/19 about 24 hours after the resident was burned;
-He/she did not contact the physician for a treatment order because he/she though the
charge nurse got a treatment order;
-He/she did not know there was not treatment order for the burn until 1/11/19 when he/she
was documenting weekly wound measurements;
-He/she measured the burn initially on 1/6/19 but did not document the measurements in the
resident’s medical record;
-He/she measured the burn at 8.5 cm x 6.5 cm. 1/8/19;
-The top layer of skin was off and the wound was open;
-The resident’s family was notified on 1/9/19 about the burn.
During interview on 1/28/19 at 8:56 A.M., the director of nurses (DON) said the following:

-After a resident spills coffee she would expect staff to notify the nurse;
-The nurse should notify the physician to get treatment orders;
-The nurse should notify the resident’s family;
-There was no policy for burns;
-She was made aware of the burn 1/11/19.

F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to screen two new employees,
(Certified Nurse Assistant (CNA) C and Dietary Aide D), in a review of ten newly hired
employees to determine if any had a Federal indicator with the Nurse Aide Registry that
would prohibit employment at the facility. The facility census was 82.
1.Review of the facility policy Employee Screening Guidelines dated 12/2016 showed the
following:
-Purpose: It is the purpose of this facility to thoroughly screen potential employees for
a history of abuse, neglect, mistreatment of [REDACTED].
b. Verify the applicant’s certification of license. For CNA/Certified Medication

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0606

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
Technician (CMT) verification may be obtained online;
c. Verify the applicant (all areas) is not listed on the CNA abuse registry, call by
contacting the Family Care Registry.
2. Review of CNA C’s employee file showed the following:
-Hired on 7/20/18;
-No evidence the facility completed the Nurse Aide Registry check upon hire.
3. Review of Dietary Aide D’s employee file showed the following:
-Hired on 7/24/18;
-No evidence the facility completed the Nurse Aide Registry check upon hire.
During interview on 11/29/18 at 9:20 A.M. the Human Resource Manager said the following:
-She was responsible for completing the background checks and screening on all new
employees, which included nurse aide registry checks;
-She could not find the nurse aide registry checks for CNA C and Dietary Aide D.
During interview on 11/29/18 at 4:35 P.M. administrator said he expected the Human
Resource Manager to complete the nurse aide registry checks on all employees upon hire.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify two residents
(Resident #8 and #73) in a review of 18 sampled residents and one additional resident
(Resident #1) and their representatives in writing of a transfer to the hospital,
including the reasons for the transfer. Further review showed the facility failed to
notify the ombudsman (a resident advocate who provides support and assistance with
problems and/or complaints regarding the facility) of the residents’ transfer to the
hospital. The facility census was 82.
1. During an interview on 11/29/18 at 3:17 P.M. the Director of Nurses (DON) said the
facility did not have a policy for ombudsman notification.
2. Record review of Resident #8’s electronic medical record showed the facility sent the
resident to the emergency roiagnom on [DATE] at 8:14 A.M. for weakness, non-productive
cough and change in condition. The resident was admitted to the hospital for treatment.
The resident planned to return to the facility.
Record review showed no documentation a letter was provided to the resident and the
resident’s representative notifying them of the resident’s transfer to the hospital and
the reason for the transfer.
3. Record review of Resident #73’s electronic medical record showed the following:
-On 10/8/18 at 3:49 P.M. the facility sent the resident to the hospital for shortness of
breath and labored breathing. The resident planned to return to the facility;
-On 10/22/18 at 2:28 P.M. facilty staff sent the resident to the hospital for tightness in
his/her chest. The resident planned to return to the facility.
Record review showed no documentation a letter was provided to the resident and the
resident’s representative(s) notifying them of the resident’s transfers to the hospital
and the reason for the transfers.
4. Review of Resident #1’s electronic medical record showed the following:
-admitted to the facility on [DATE];

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
-On 10/13/18 at 9:22 A.M. the resident had mental status changes. Order received by the
physician to send the resident to the emergency room to be evaluated;
-On 10/13/18 at 12:30 P.M. received call that resident was being transferred to a critical
care hospital to be admitted for [MEDICAL CONDITION] (high potassium), dehydration,
[MEDICAL CONDITION] and mental status changes;
-On 10/23/18 at 4:25 P.M. the resident returned to the facility.
Record review showed no documentation a letter was provided to the resident and the
resident’s representative notifying them of the resident’s transfer to the hospital and
the reason for the transfer.
5. During an interview on 11/19/18 at 3:58 P.M., the ombudsman said the facility was not
contacting or sending reports to him/her regarding the residents’ discharges.
During an interview on 11/28/18 at 1:36 P.M., the social service designee (SSD) said she
was responsible for notifying the ombudsman and the resident/resident’s representative of
resident discharges. She was not aware she was supposed to notify the ombudsman or the
resident/resident’s representative of resident discharges to hospitals or facility
initiated discharges. He/she has not been notifying the ombudsman or resident/resident’s
representative of any resident discharges.
During an interview on 11/29/18 at 4:34 P.M., the administrator said he would expect the
SSD to contact the ombudsman per regulatory guidelines.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, and record review, the facility failed to complete a significant
change in status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, for one resident (Resident #8), in a review of 18
sampled residents and one additional resident (Resident #41), within 14 days after the
residents enrolled in a hospice program. The facility census was 82.
1. Review of the undated facility policy SCSA showed a SCSA is required to be performed
when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other
structured hospice) and remains a resident at the nursing home. The Assessment Reference
Date (ARD) must be within 14 days from the effective date of the hospice election (which
can be the same or later than the date of the hospice election statement, but not earlier
than). A SCSA must be performed regardless of whether an assessment was recently conducted
on the resident.
2. Review of the Long Term Care Facility Resident Assessment Instrument (RAI) User’s
Manual, version 3.0 updated (MONTH) (YEAR) showed a SCSA is required to be performed when
a terminally ill resident enrolls in a hospice program (Medicare-certified or
state-licensed hospice provider) or changes hospice providers and remains a resident at
the facility. This is to ensure a coordinated plan of care between the hospice and
facility is in place. A Medicare-certified hospice must conduct an assessment at the
initiation of its services. This is an appropriate time for the facility to evaluate the
MDS information to determine if it reflects the current condition of the resident, since
the facility remains responsible for providing necessary care and services to assist the
resident in achieving his/her highest practicable well-being at whatever stage of the
disease process the resident is experiencing.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
3. Review of Resident #8’s census report showed the following:
-admitted to the facility on [DATE]-payer Medicare Part A;
-discharged to the hospital on [DATE];
-Returned to the facility 6/7/18, payer hospice private.
Review of the resident’s admission MDS dated [DATE] showed hospice services were not
marked.
Review of the resident’s Facility Notification of Admission completed by the hospice
company showed the following:
-Date of hospice admission: 6/7/18;
-Resident was admitted to our service for the following hospice Diagnosis: [REDACTED].
Review of the resident’s quarterly MDS dated [DATE] showed hospice services were not
marked.
Review of the resident’s medical record showed no significant change MDS completed after
the resident elected the hospice benefit.
4. Review of Resident #41’s face sheet showed the resident was admitted to the facility on
[DATE].
Review of the resident’s admission MDS dated [DATE] showed hospice services were not
marked.
Review of the resident’s quarterly MDS dated [DATE] showed hospice services were not
marked.
Review of the resident’s progress notes dated 8/23/18 at 1:01 P.M. showed the following:
-Hospice here to evaluate resident per family request;
-Physician notified and in agreement with whatever the family wants.
Review of the resident’s census report showed on 8/23/18 the resident’s payer changed to
hospice private.
Review of the resident’s quarterly MDS dated [DATE] showed hospice services were not
marked.
Review of the resident’s medical record showed no significant change MDS completed after
the resident elected the hospice benefit.
5. During interview on 11/29/18 at 3:14 P.M. the MDS Coordinator said the following:
-He/She uses the RAI manual as a reference when completing MDS assessments;
-A significant change MDS should be completed when an improvement or decline in condition
lasts more than 14 days and when a resident elects the hospice benefit;
-Resident #41 and #8 were receiving hospice services prior to his/her employment for the
facility.
6. During interview on 11/29/18 at 4:06 P.M. the Director of Nurses (DON) said the
following:
-She would expect a SCSA to be completed when a resident elects the hospice benefit;
-The facility’s MDS staff was new.

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to develop and implement a base
line care plan consistent with the resident’s specific conditions, needs and risks to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
provide effective person centered care that met professional standards of quality care
within 48 hours of admission to the facility for one resident (Resident #45) in a review
of 18 sampled residents and two additional residents (Resident #74 and #200). The facility
census was 82.
1. During interview on 11/29/18 at 4:06P.M. thee Director of Nursing (DON) said the
facility had no policy in place for completing baseline care plans.
2. Review of Resident #45’s face sheet showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes dated 10/3/18 at 2:10 P.M. showed the following:
-Resident arrived by facility transport;
-Sight and hearing poor;
-Oxygen at 2 liters per minute by nasal cannula with saturation (the extent to which
hemoglobin is saturated with oxygen) at 91% (normal 95 to 100%);
-Incontinent of bowel and bladder with briefs worn;
-Requires assist of one with transfers and activities of daily living (ADLs).
Review of the resident’s medical record showed no baseline care plan to meet the
resident’s immediate needs completed within 48 hours of facility admission.
3. Review of Resident # 200’s face sheet showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes dated 11/23/18 at 1:15 P.M. showed the following:
-Arrived to facility at 11:45 A.M. in facility van to unit in wheelchair propelled by
staff;
-admitted to Medicare A bed due to bilateral pneumonia;
-Oxygen worn at all times at 4 liters per minute per nasal cannula;
-Alert and oriented time three, forgetful poor cognitive skills;
-Needs assist to transfer full weight bear, balance is fair.
Review of the resident’s progress notes dated 11/25/18 at 8:30 P.M. showed the resident is
coughing up bright red blood.
Review of the resident’s physician’s orders [REDACTED].
-[MEDICATION NAME] (a rapid-acting human insulin analog used to lower blood glucose)
[MEDICATION NAME] U-100 insulin cartridge; 100 units/milliliter (ml) give 6 units
subcutaneous with meals;
-Oxygen at 4 liters per minute per nasal cannula as needed (PRN).
Review of the resident’s medical record showed no baseline plan of care to meet the
resident’s immediate needs completed within 48 hours of facility admission.
4. Review of Resident #74’s face sheet showed the following:
-admitted to the facility on [DATE];
-[DIAGNOSES REDACTED].
Review of the resident’s progress notes dated 10/31/18 at 5:54 A.M. showed the following:
-Resident is receiving skilled nursing care for [MEDICAL CONDITION] (skin infection);
-Treatments in place to bilateral lower extremities at this time;
-The resident is incontinent of bowel and bladder;
-He/she requires extensive assist with transfers and ADLs.
Review of the resident’s medical record showed no baseline plan of care to meet the
resident’s immediate needs completed within 48 hours of facility admission.
8. During interview on 11/29/18 at 4:06 P.M. the Director of Nursing said the following:
-The admitting charge nurse is responsible for completing baseline care plans;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-The baseline care plans for Residents #45, #74 and #200 could not be located.

F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless
contraindicated, prior to initiating or instead of continuing psychotropic medication; and
PRN orders for psychotropic medications are only used when the medication is necessary and
PRN use is limited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain a system to monitor
residents who used psychopharmacological medications to ensure attempts were made for
gradual dose reductions (GDR) in an effort to reduce or discontinue these medications for
one resident (Resident #25), in a review of 18 sampled residents and three additional
residents (Resident #27, Resident #65, and Resident #68). The facility census was 82.
1. Review of the facility policy Medication Monitoring/Medication Management revised
(MONTH) 2014 showed the following:
Antipsychotics: If a resident is admitted on an antipsychotic medication or the facility
initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters
(with at least one month between the attempts) within the first year, unless clinically
contraindicated. After the first year, a GDR must be attempted annually, unless clinically
contraindicated;
1. A GDR is considered clinically contraindicated if:
a) Target symptoms returned or worsened after the most recent attempt at a GDR and the
physician documents the clinical rationale for why any additional attempted dose
reductions would likely impair the resident’s function, increase distressed behavior, or
cause psychiatric instability by exacerbating an underlying medical or psychiatric
condition-OR-
b) The continued use is in accordance with relevant current standard of practice and the
physician documents the clinical rationale for why any additional attempted dose
reductions would likely impair the resident’s function, increase distressed behavior, or
cause psychiatric instability by exacerbating an underlying medical or psychiatric
condition;
Other psychopharmacologic medications: [REDACTED]
After the first year, a tapering should be attempted annually, unless clinically
contraindicated;
1. A GDR is considered clinically contraindicated if:
a) Target symptoms returned or worsened after the most recent attempt at a GDR and the
physician documents the clinical rationale for why any additional attempted dose
reductions would likely impair the resident’s function, increase distressed behavior, or
cause psychiatric instability by exacerbating an underlying medical or psychiatric
condition-OR-
b) The continued use is in accordance with relevant current standard of practice and the
physician documents the clinical rationale for why any additional attempted dose
reductions would likely impair the resident’s function, increase distressed behavior, or
cause psychiatric instability by exacerbating an underlying medical or psychiatric
condition.
2. Review of the facility policy Drug Review dated (MONTH) (YEAR) showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-Medications should not show unnecessary or excessive use and should have a [DIAGNOSES
REDACTED].
-Problems identified shall be addressed according to need in consultation with the
physician;
Reviewing antipsychotic drugs:
-Antipsychotic drugs should only be given when necessary to treat a specific condition;
-Determine the most acceptable timeframe to attempt reduction of drug dosage from behavior
evaluation;
-Notify physician of finding and recommendations. Obtain an order for [REDACTED].>3.
Review of Resident #25’s face sheet showed an admission date of [DATE].
Review of the resident’s physician’s orders showed the following:
-[MEDICATION NAME] (anti-anxiety medication)1mg by mouth at bedtime (start date 12/8/17);
-[MEDICATION NAME] (anti-depressant medication) sustained release (SR) 150 mg by mouth
daily (start date 12/12/17).
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Cognitively intact;
-No behaviors;
-[DIAGNOSES REDACTED].
-Received anti-anxiety medication seven of the last seven days;
-Received anti-depressant medication seven of the last seven days;
-Antipsychotics were received on a routine basis;
-A GDR has not been attempted;
-A GDR has not been documented by a physician as clinically contraindicated.
Review of the resident’s behavioral health nursing home follow-up evaluation dated 9/20/18
showed the following:
-Impression: [MEDICAL CONDITION], severe with psychotic features;
-Plan: continue current medication.
Review of the pharmacist’s Note to Attending Physician/Prescriber dated 9/27/18 showed the
following:
-Current order: [MEDICATION NAME] 1 mg at bedtime;
-CMS requires periodic trial dosage reductions to determine if symptoms can be controlled
with a lower dose or without the medication;
-Recommendation: Please consider a trial reduction to [MEDICATION NAME] 0.5 mg at bedtime.
If a GDR is clinically contraindicated at this time, please document the clinical
rationale. This must address the reason(s) why an attempted dose reduction would likely
impair function or cause psychiatric instability by exacerbating an underlying medical or
psychiatric disorder;
*NOTE* Dose reductions for controlled substances require a new prescription. If this dose
reduction is accepted, please write a new prescription and fax to pharmacy;
-Signed by the pharmacist;
-Physician/prescriber response: blank.
Review of the resident’s care plan last revised 10/4/18 showed the following:
-Potential for drug related complications associated with use of [MEDICAL CONDITION]
medication related to: anti-anxiety medication, anti-depressant medication, and
anti-psychotic medication for the treatment of [REDACTED].
-Provide medications as ordered by physician and evaluate for effectiveness.
Review of the resident’s medical record showed no documentation or communication
requesting a GDR for [MEDICATION NAME] and no response from the physician regarding the
GDR request for [MEDICATION NAME].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
3. Review of Resident #27’s physician’s orders showed the following:
-[MEDICATION NAME] (anti-anxiety medication) 5 mg by mouth twice a day (start date
10/4/16);
-Amitriptylline (anti-depressant medication) 10 mg by mouth at bedtime (start date
10/4/16).
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Received antianxiety medication seven of the last seven days;
-Received antidepressant medication seven of the last seven days.
Review of the resident’s care plan last revised 9/21/18 showed the following:
-Potential for drug related complications associated with use of [MEDICAL CONDITION]
medications related to anti-depressant and anti-anxiety medication;
-Provide medications as ordered by physician and evaluate for effectiveness;
-[MEDICAL CONDITION] medication risk/benefit and reduction plan as recommended by
physician and pharmacist.
Review of the resident’s medical record showed no documentation of a request for a GDR or
a GDR completed for [MEDICATION NAME] or amitriptylline.
4. Review of Resident #65’s pharmacist consultation report dated 8/31/18 showed the
following:
-Resident’s current order [MEDICATION NAME] (prescription drug used to treat panic
attacks, certain types of [MEDICAL CONDITION], and the short-term relief of the symptoms
of anxiety.) 0.5 mg twice a day, [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]
([MEDICATION NAME][MEDICATION NAME]) is an [MEDICATION NAME] used to treat allergies
[REDACTED].
quetapine (is an antipsychotic medicine. It works by changing the actions of chemicals in
the brain. It is used to treat [MEDICAL CONDITIONS] and other mental illness) 25 mg at
bedtime;
-Resident has been on all of these medications for over a year. In light of recent falls
and within the first year a resident is admitted on an antipsychotic medication,
antidepressant, or anxiolytic medication a GDR must be attempted in two separate quarters
(with at least one month between the attempts), unless clinically contraindicated. After
the first year, a GDR must be attempted annually, unless contraindicated;
-Recommendation: Please review the above medications an if clinically appropriate, please
consider a dosage reduction on one or all of the medications. If a GDR is clinically
contraindicated at this time, please document the clinical rationale. This must address
the reasons why an attempted dose reduction would likely impair function or cause
psychiatric instability by exacerbating and underlying medical or psychiatric disorder;
-Physician’s response was blank;
-Physician signature was blank.
Review of the resident’s electronic medical record (EMR) active physician’s orders showed
the following:
-Start date 4/15/17 [MEDICATION NAME] 0.5 mg twice a day intravenous (IV). No end date;
-Start date 3/25/17 [MEDICATION NAME][MEDICATION NAME] 25 mg two tablets twice a day. No
end date;
-Start date 3/10/17 quetiapine 25 mg on tablet at bedtime. No end date.
Review of the resident’s EMR showed the resident’s current [DIAGNOSES REDACTED].
Review of the resident’s quarterly change Minimum Data Set (MDS), a federally mandated
assessment instrument, dated 11/5/18 showed the following:
-Moderately cognitively impaired;
-One fall with no injury since admission or prior assessment;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 14)
-Received antipsychotic medication seven of the last seven days;
-Anti-psychotic received on a routine basis only;
-Staff indicated a GDR had not been attempted;
-GDR has not been documented by a physician as clinically contraindicated.
5. Review of Resident #68’s physician’s orders showed the following:
-[DIAGNOSES REDACTED].
-[MEDICATION NAME] (antipsychotic medication) 25mg by mouth twice a day (start date
4/24/17);
-[MEDICATION NAME] 0.5mg by mouth twice a day (start date 5/30/17);
-[MEDICATION NAME] 10mg give three tablets by mouth daily (start date 4/20/17).
Review of the resident’s quarterly MDS dated [DATE] showed the following:
-Received antianxiety medication seven of the last seven days;
-Received antipsychotic medication seven of the last seven days;
-Received antidepressant medication zero of the last seven days;
-Antipsychotics were received on a routine basis only;
-A GDR has not been attempted;
-A GDR has not been documented by a physician as clinically contraindicated.
Review of the resident’s Consultant Pharmacist’s Medication Regimen Review Recommendations
Pending a Final Response dated 4/27/18 showed the following:
Current order: [MEDICATION NAME] 30mg daily since 4/20/17;
-CMS guidelines require periodic review of antidepressants for potential reductions in
dose to determine if the symptoms can be controlled utilizing a lower dose or if the
antidepressant can be discontinued;
-Recommendation: Please consider a trial dose reduction to [MEDICATION NAME] 20mg daily;
If a GDR is clinically contraindicated at this time, please document the clinical
rationale below. This must address the reason(s) why an attempted dose reduction would
likely impair the resident’s function or cause psychiatric instability by exacerbating an
underlying medical or psychiatric disorder;
-Plan: same. Initialed by the physician.
Review of the resident’s Note to Attending Physician/Prescriber dated 5/30/18 showed the
following:
Current order: [MEDICATION NAME] 25mg twice daily since 4/24/17;
-Within the first year a resident is admitted on an antipsychotic medication, or after an
antipsychotic medication has been initiated in the facility, a GDR must be attempted in
two separate quarters (with at least one month between the attempts), unless clinically
contraindicated. After the first year, a GDR must be attempted annually, unless clinically
contraindicated;
-Recommendation: Please consider reducing the current medication dose to [MEDICATION NAME]
25mg at bedtime;
-If a GDR is clinically contraindicated at this time, please document the clinical
rationale below. This must address the reason(s) why an attempted dose reduction would
likely impair the resident’s function or cause psychiatric instability by exacerbating an
underlying medical or psychiatric disorder;
Physician response:
Marked disagree. Rationale blank. Plan same;
Signed by the physician on 6/13/18.
Review of the resident’s Note to Attending Physician/Prescriber dated 7/29/18 showed the
following:
Current order: [MEDICATION NAME] 25mg twice daily since 4/24/17;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0758

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 15)
-Within the first year a resident is admitted on an antipsychotic medication, or after an
antipsychotic medication has been initiated in the facility, a GDR must be attempted in
two separate quarters (with at least one month between the attempts), unless clinically
contraindicated. After the first year, a GDR must be attempted annually, unless clinically
contraindicated;
-Recommendation: Please consider reducing the current medication dose to [MEDICATION NAME]
25mg at bedtime;
-If a GDR is clinically contraindicated at this time, please document the clinical
rationale below. This must address the reason(s) why an attempted dose reduction would
likely impair the resident’s function or cause psychiatric instability by exacerbating an
underlying medical or psychiatric disorder;
-Physician response: plan: same;
-Signed by the physician on 9/17/18.
Review of the resident’s progress notes dated 9/18/18 at 9:09 A.M. showed the pharmacy
recommended a GDR on the resident’s [MEDICATION NAME] 25mg. Physician has declined this
recommendation at this time.
Review of the resident’s care plan last revised 11/13/18 showed the following:
-Potential for drug related complications associated with use of [MEDICAL CONDITION]
medication related to: anti-depressant and antianxiety/antipsychotic for dementia with
behaviors and [MEDICAL CONDITION] with delusions;
-Monthly pharmacy review of medication regimen;
-[MEDICAL CONDITION] medication risk/benefit and reduction plan as recommended by
physician and pharmacist.
Review of the resident’s medical record showed no documentation of a request for a GDR or
a GDR completed for [MEDICATION NAME].
6. During interview on 11/29/18 at 4:06 P.M. the Director of Nursing (DON) said the
following:
-She is responsible for monitoring pharmacist recommendations and GDR requests;
-She is responsible for ensuring physician response to pharmacist recommendations and GDR
requests;
-She would expect the physician to respond timely and appropriately to pharmacist
recommendations and GDR requests within 72 hours of the recommendation or request;
-She would expect if the physician disagrees with the pharmacist recommendation to give a
rationale why he/she disagrees;
-If the physician documents same that would mean to continue the medication order;
-Some physicians never respond to pharmacist recommendations.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure nursing
staff washed their hands and changed soiled gloves after each direct resident contact and
when indicated by professional practices during personal care for three residents
(Resident #25, #45 and #64) in a review of 18 sampled residents. The facility census was
82.
1. Review of the facility policy Handwashing dated (MONTH) (YEAR) showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 16)
Purpose: To reduce the transmission of organisms from:
-Resident to resident;
-Nursing staff to resident;
-Resident to nursing staff.
2. Review of the facility policy Gloves dated (MONTH) (YEAR) 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. Gloves must be changed between residents and
between contacts with different body sites of the same resident;
-Remember: gloves are not a cure-all. They should reduce the likelihood of contaminating
the hands, but gloves cannot prevent penetrating injuries due to needles or sharp objects.
Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a
glove easier than to the skin on your hands. Handling medical equipment and devices with
contaminated gloves is not acceptable.
3. Review of the Nurse Assistant in a Long-term Care Facility, 2001 Revision edition,
regarding hand washing and use of gloves, showed the following:
-Wash hands before and after glove use and after contact with any waste or contaminated
material;
-Gloves should be worn when contact is likely with the following: anybody opening, blood,
all moist body fluids, mucous membranes (nose, mouth, etc.), non-intact skin (pressure
ulcers, skin tears), dressings, used tissues or wipes, surfaces or items contaminated with
blood or body fluids, specimen containers being transported;
-Use gloves when doing mouth care, perineal care, skin care, and other procedures
involving body fluids;
-Gloves do not eliminate the need to wash your hands; they just provide a barrier between
you and potentially infectious microorganisms;
-Never touch unnecessary articles in the room or one’s face, hair, contact lens, or
glasses when wearing gloves.
4. Review of Resident #45’s admission MDS dated [DATE] showed the following:
-Short and long term memory problems;
-Limited assist of two or more staff for toilet use;
-Limited assist of one staff for personal hygiene;
-Always incontinent of bladder and bowel.
Review of the resident’s care plan dated 10/23/18 showed the following:
-Staff to provide toileting assistance every two hours;
-Staff to provide incontinence care after each incontinent episode.
Observation on 11/28/18 at 7:27 A.M. in the resident’s room showed the following:
-CNA N and CNA O entered the resident’s room;
-The resident lay in bed. He/she was incontinent of urine and stool;
-With gloved hands, CNA N tucked the resident’s soiled brief;
-With gloved hands, CNA O provided pericare and removed the soiled brief. Stool was
visible on the disposable wipes;
-Without changing gloves or washing his/her hands, CNA O placed a clean brief under the
resident’s hips;
-With the same gloved hands, CNA N and CNA O rolled the resident to his/her back;
-With the same gloved hands, CNA O fastened the clean brief, touched the resident’s right
leg and right hand, picked up the package of disposable wipes and placed the package in
the drawer;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 17)
-With the same gloved hands, CNA N and CNA O pulled up the resident’s clean pajama pants;
-With the same gloved hands, CNA N removed the oxygen tubing from the resident’s nose;
-With the same gloved hands, CNA O touched the wheelchair, pushed it to the bedside and
locked the brakes, picked up the cloth lift pad and assisted the resident to sit up on the
side of the bed. CNA O touched the resident’s hair and attempted to smooth it down while
CNA N removed the resident’s shirt;
-With the same gloved hands, CNA O applied the resident’s clean shirt, helped place the
cloth lift pad around resident’s back and hooked the lift pad up to mechanical stand up
lift;
-CNA N and CNA O transferred the resident from the bed to the wheelchair;
-With the same gloved hands, CNA O removed the resident’s bed linens;
-With the same gloved hands, CNA N washed the resident’s face and brushed the resident’s
hair;
-CNA O removed his/her gloves and without washing his/her hands pushed the resident to the
dining room in his/her wheelchair.
Observation on 11/28/18 at 1:40 P.M. in the resident’s room showed the following:
-CNA N and CNA O transferred the resident from his/her wheelchair to his/her bed;
-The resident’s incontinence brief was saturated with urine;
-With gloved hands, CNA N unfastened the brief and provided pericare;
-With the same gloved hands, CNA N picked up and moved the package of wipes and touched
the clean incontinence brief;
-With the same gloved hands, CNA N placed the clean brief under the resident’s hips,
picked up the tube of barrier cream and applied barrier cream to resident’s groin area;
-With the same gloved hands, CNA N and CNA O fastened the clean brief;
-CNA N removed his/her gloves and without washing his/her hands, turned on the oxygen
concentrator.
5. Review of Resident #25’s quarterly MDS dated [DATE] showed the following:
-Cognitively intact;
-Totally dependent on one staff for personal hygiene;
-Totally dependent on two or more staff for toilet use;
-Frequently incontinent of urine and stool.
Review of the resident’s care plan last revised 10/12/18 showed the resident was dependent
for care.
Observation on 11/28/18 at 7:48 A.M. in the resident’s room showed the following:
-The resident lay in bed;
-He/she urinated in the bedpan;
-With gloved hands, CNA N provided pericare;
-With the same soiled gloved hands, CNA N went to the closet, opened the closet door and
removed a clean incontinence brief;
-With the same soiled gloved hands, CNA N placed the clean brief and cloth lift sling
under the resident’s hips;
-With the same soiled gloved hands, CNA N touched the privacy curtain, pushed the
mechanical lift to the bedside, touched the lift controls and applied clean socks on the
resident’s feet;
-CNA N removed his/her gloves, held the soiled gloves in his/her left hand and without
washing hands brushed the resident’s hair with his/her right hand.
6. Review of Resident #64’s care plan last revised 9/21/18 showed the following:
-Resident required assistance with ADLS;
-Required one to two assistance of staff for toileting;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 18)
-Required two staff assistance for transfers;
-Incontinent of bladder at times.
Review of the resident’s annual MDS dated [DATE] showed the following:
-Cognitively intact;
-Extensive assistance of two or more staff for toileting;
-Always continent of bowel;
-Occasionally incontinent of bladder.
Observation on 11/28/18 at 8:10 A.M. showed the following:
-The resident sat on the toilet with a sling around his/her body and a sit to stand lift
in front of him/her;
-The resident had a bowel movement and urinated in the toilet;
-CNA N put gloves on, used the control on the lift to raise the resident off the toilet;
-With gloved hands CNA N provided rectal perineal care and removed the resident’s used
brief from between the resident’s legs;
-Without removing his/her soiled gloves or washing his/her hands, CNA N put a clean brief
on the resident;
-With the same soiled gloves, CNA N pulled the resident’s pants up around his/her waist,
touched the control on the sit to stand lift and transferred the resident into his/her
wheelchair;
-With the same soiled gloves, CNA N pulled the resident’s shirt down his/her back touching
the resident’s arms and back;
-With the same soiled gloves, CNA N removed the sling from around the resident touching
the bar of the lift and the controls to the lift;
-CNA N removed his/her soiled gloves and prior to washing his/her hands opened the
bathroom door for the resident.
During an interview on 11/28/18 at 2:28 P.M. CNA N said he/she was transferring the
resident with the sit to stand by him/herself and was rushing and forgot to change gloves
and wash his/her hands prior to putting gloves on and after providing perineal care.
During an interview on 11/29/18 at 4:05 P.M. the director of nursing (DON) said the
following:
-She expected staff to wash hands prior to putting gloves on and after removing gloves;
-She expected to change gloves when they become soiled and after providing perineal care.

F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement policies and procedures for flu and pneumonia vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop policies and
procedures to ensure an influenza and pneumococcal vaccine program was appropriately
implemented for residents. Staff failed to document residents were assessed, offered and
declined or received influenza (flu) and /or pneumococcal vaccines and failed to provide
education regarding risks and benefits of receiving the vaccines for two of 18 sampled
residents (Residents #7 and #45). The facility census was 82.
1. Review of the facility policy Immunizations dated (MONTH) (YEAR), showed the following:
-Influenza: recommended annually for all residents;
-Pneumococcal recommended for residents [AGE] years or older. A repeat dose after six

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
years may be given to those at highest risk;
-Consult the resident’s physician to determine the level of risk and need for the vaccine.
The facility policy and procedure did not include the following:
-Before offering the influenza immunization, each resident or the resident’s legal
representative received education regarding the benefits and potential side effect of the
immunization. Each resident was offered an influenza immunization (MONTH) 1 through
(MONTH) 31 annually, unless the immunization was medically contraindicated or the resident
had already been immunized during this period. The resident or the resident’s legal
representative had the opportunity to refuse immunization and the resident’s medical
record included documentation that indicated, at a minimum that the resident or resident’s
legal representative was provided education regarding the benefits and potential side
effects of influenza immunization and that the resident either received the influenza
immunization or did not receive the influenza immunization due to medical
contraindications or refusal;
-Each resident was offered a pneumococcal immunization, unless the immunization was
medically contraindicated or the resident had already been immunized. Did not specify
which pneumococcal vaccine was to be used and when. The resident or the resident’s legal
representative had the opportunity to refuse immunization and the resident’s medical
record included documentation that indicated, at a minimum that the resident or resident’s
legal representative was provided education regarding the benefits and potential side
effects of pneumococcal immunization and that the resident either received the
pneumococcal immunization or did not receive the pneumococcal immunization due to medical
contraindications or refusal.
2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine
Timing for Adults dated 11/30/15 showed the following:
-Two pneumococcal vaccines are recommended for adults: 13-valent pneumococcal conjugate
vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23,
[MEDICATION NAME] 23);
-One dose of PCV 13 was recommended for adults [AGE] years or older who had not previously
received PCV13;
-One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of
previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was
given at age [AGE] years or older, no additional doses of PPSV23 should be administered;
-For those age [AGE] years or older who had not received any pneumococcal vaccines, or
those with unknown vaccination history, administer one dose of PCV13. Administer one dose
of PPSV23 at least one year later for most adults or at least eight weeks later for adults
with immunocompromising conditions;
-For those age [AGE] years or older who previously received one dose of PPSV 23 and no
doses of PCV13 administer one dose of PCV13 at least one year after the dose of PPSV23 for
all adults regardless of medical conditions.
3. Review of Resident #7’s face sheet showed an admission date of [DATE].
Review of the resident’s immunization consent or refusal showed the following:
-The resident refused consent for: staff failed to document what the resident refused
consent for;
-Date resident last received pneumococcal was blank;
-The resident signed and dated the consent on 9/21/16;
-The social service designee signed the consent as a witness;
-At the bottom of the form was a the following statement: if the resident or
responsibility party sign that consent is given for the immunization to be administered,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
they will not have to re-sign this form for the remainder of the resident’s stay a at
facility. However, if there is a change in the decision to consent for this immunization
they may do so but must notify the facility of this decision of change.
Review of the resident’s preventive health care record showed the following:
-On 10/28/17 staff did not administer the flu vaccine to the resident;
-On 10/28/17 staff did not administer the pneumococcal vaccine to the resident and the
resident had not received pneumococcal vaccine.
Record review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, dated 11/23/18, showed the following:
-Cognitively intact;
-Staff documented the resident did not receive the current year (2018) influenza vaccine
in the facility due to the resident declined the vaccine;
-Staff documented the resident’s pneumococcal vaccine was up to date. There was no date
documented for the vaccine.
Review of the resident’s record on 11/29/18, showed the following:
-No documentation staff provided the resident or legal representative education regarding
the (YEAR) influenza vaccine or documentation the resident or legal representative
accepted or declined the vaccine;
-No documentation staff followed up with pneumococcal vaccine or offered/provided the
resident the pneumococcal vaccine or provided education regarding the pneumococcal vaccine
or documentation the resident accepted or declined the vaccine after admission or that the
resident had received the pneumococcal vaccine.
3. Review of Resident #45’s face sheet showed an admission date of [DATE].
Review of the resident’s immunization consent or refusal showed the following:
-The resident refused consent for: staff failed to document what the resident refused
consent for;
-Date resident last received pneumococcal was blank;
-The resident’s family member signed and dated the consent on 10/3/18;
-The social service designee signed the consent as a witness;
-At the bottom of the form was a the following statement: if the resident or
responsibility party sign that consent is given for the immunization to be administered,
they will not have to resign this form for the remainder of the resident’s stay a at
facility. However, if there is a change in the decision to consent for this immunization
they may do so but must notify the facility of this decision of change.
Review of the resident’s electronic medical health record showed the preventative health
care record was blank.
Record review of the resident’s admission MDS dated [DATE] showed the following:
-Short and long term memory problems;
-Staff documented the resident’s pneumococcal vaccine was up to date. There was no date
documented for the vaccine.
Review of the resident’s record on 11/29/18, showed no documentation staff followed up
with pneumococcal vaccine or offered/provided the resident the pneumococcal vaccine or
provided education regarding the pneumococcal vaccine or documentation the resident
accepted or declined the vaccine after admission or that the resident had received the
pneumococcal vaccine.
4. During an interview on 11/29/18 at 2:21 P.M. the SSD said the following:
-She was responsible upon admission to give the resident’s the consent form for
pneumococcal and the flu vaccine;
-She did not provide any education to the resident’s regarding the vaccines at the time
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0883

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
she got consent for the vaccines from the residents;
-The nursing staff was responsible for getting the date for when the residents received
the pneumococcal vaccine and for following up on the pneumococcal vaccine;
-If the resident signs refused or consent and it is not indicated which vaccine they are
referring to that means they are giving consent or refusing both the flu and pneumococcal
vaccines.
During an interview on 11/29/18 at 3:17 P.M. the director of nursing (DON) said the
following:
-The residents sign a consent upon admission and the consent is effective the entire time
the resident is living in the facility;
-She went around and verbally asked all the residents when she was hired;
-If a resident refuses a vaccine once, the facility does not re-educate or ask the
resident again if they want the vaccine;
-The facility used CDC educational material to educate the residents prior to given the
flu vaccine;
-The facility did not give educational material to the residents for pneumococcal vaccine
as it was regulated by the residents’ physicians;
-She would expect staff to educate the residents when getting consent or refusal on
admission.
During an interview on 11/29/18 at 4:23 P.M. the administrator said he would expect staff
to follow CDC guidelines and the facility policy for administering the flu and
pneumococcal vaccines to residents.

F 0926

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Have policies on smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review the facility failed to establish a policy, in
accordance with applicable Federal, State, and local laws and regulations, regarding
smoking, smoking areas, and smoking safety that also takes into account non smoking
residents. The facility had a written policy that residents may smoke with supervision in
designated areas, but verbally considered itself a non smoking facility for residents
only. Residents and staff did smoke at the facility. The facility census was 82.
1. Review of the undated smoking policy provided by the administrator, included in the
admission packet, and given to the resident’s upon admission showed the following:
-For safety reasons, the resident and any visitor to the facility is hereby advised not to
smoke except under supervision and/or in designated smoking areas;
-Residents may not retain matches or lighters.
(The policy did not address safety concerns for smoking and non smoking residents
including use of oxygen, systems for resident assessment and ability to smoke safely, safe
smoking areas, safety equipment if indicated or staff responsible for assessment,
implementation and supervision).
2. During an interview on 11/26/18 at 2:24 P.M. the administrator said the facility was a
non smoking facility and they did not have any residents that smoked. All residents that
were admitted that previously smoked were offered the smoking patch or gum upon admission
or had to be signed out of the facility to smoke.
3. Review of the list of residents who smoked provided by the facility on 11/27/18, showed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0926

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
Resident #62 smoked prior to admission.
4. Review of the Resident #62’s medical record showed a form titled resident rules and
regulations which included the smoking policy. The resident’s signature and dated 4/26/18.

Review of the resident’s smoking risk assessment completed by staff on admitted d 4/26/18
showed the resident was a safe smoker, to follow facility policy.
Review of the resident’s admission Minimum Data Set, (MDS), a federally mandated
assessment instrument to be completed by facility staff, dated 5/3/18 showed the
following:
-Able to make needs known and understood others;
-Short term and long term memory was ok;
-Independent with daily decision making;
-Very important to do his/her favorite activities;
-Required extensive assistance of one staff for locomotion on and off the unit;
-Required limited assistance of one staff for transfers and bed mobility;
-[DIAGNOSES REDACTED].>-No tobacco use.
During an interview on 11/26/18 at 02:55 P.M. the resident said the following:
-He/she was able to smoke in a designated place outside where staff smoked;
-Staff sometimes took him/her out but they weren’t supposed to do this.
During interview on 11/29/18 at 9:40 A.M. the resident said the following:
-He/she felt like he/she should be able to smoke;
-He/she didn’t understand why the staff couldn’t take him/her out when they go outside to
smoke;
-Staff had taken him/her out to smoke with them before but he/she had not been out for
about four days and they won’t take him/her out as long as state was in the building;
-The administrator didn’t want him/her to smoke, but the facility’s corporate office
didn’t say it was a no smoking facility.
5. Review of the Resident #7’s medical record showed a form titled resident rules and
regulations which included the smoking policy. The resident’s signature and dated 9/21/16.

Review of the resident’s smoking risk assessment completed by staff dated 2/19/18, showed
the resident was a safe smoker, to follow facility policy.
Review of the the resident’s quarterly MDS dated [DATE] showed the following:
-The resident was cognitively intact;
-[DIAGNOSES REDACTED].
-Required supervision of one staff for locomotion on the unit and transfers;
-Required limited assistance of one staff for locomotion off the unit, dressing and toilet
use;
-Staff failed to document tobacco use (blank).
During an interview on 11/28/18 at 11:30 A.M. the resident said:
-He/she had been a smoker for many years;
-He/she did not understand reason staff could smoke but he/she could not.
6. During interview on 11/28/18 at 1:32 P.M., Certified Nurse Assistant (CNA) C said the
following:
-There were residents that smoked who lived at the facility;
-Resident #62 smoked out in the court yard on the south hallway with whoever would take
him/her outside to smoke;
-Resident #62 said the facility use to be a smoking facility and the resident got a hold
of the policy that said it was a smoking facility and reported to staff and the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0926

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 23)
administrator that it was his/her right to smoke.
During an interview on 11/28/18 at 2:28 P.M. CNA N said the following:
-The facility was smoke free for the residents;
-The staff were allowed to smoke outside in back;
-Resident #7 and Resident #62 liked to smoke;
-Residents’ friends and family could take them outside to smoke but staff were not allowed
to take residents outside to smoke.
During an interview on 11/29/18 at 9:53 A.M. CNA K said the following:-Resident #7 and
Resident #62 could safely smoke and hold their own cigarettes;
-The staff smoke but the residents were not allowed to smoke;
-The facility use to be a smoking facility then went to no smoking for residents;
-Resident #62 would get really upset when staff go out and he/she can’t go out to smoke.
During an interview on 11/29/18 at 9:44 A.M. Licensed Practical Nurse (LPN) J said the
following;
-The facility use to be smoking then went to no smoking on campus and currently was non
smoking for residents;
-The licensed staff complete smoking assessments on the residents on admission but they do
not do them quarterly since the residents aren’t able to smoke.
During an interview on 11/29/18 at 10:46 A.M. LPN M said the following:
-The licensed nurses were responsible for completing smoking assessments for the residents
upon admission only;
-The did not complete smoking assessments quarterly on the residents;
-The facility was a non smoking facility;
-The staff can smoke but not the residents;
-Upon admission he/she educated the residents that are admitted to the facility being non
smoking.
During an interview on 11/29/18 at 9:56 A.M. the social service designee (SSD) said the
following:
-The facility was currently non smoking for the residents;
-The residents are told verbally about the facility being non smoking prior to admission;
-The facility did not have a policy that showed it was non smoking;
-The facility use to be a smoking facility but five to six years ago they changed to non
smoking for staff and residents;
-The staff gradually started smoking again but the residents have not been allowed to
smoke.
During interview 11/29/18 at 4:05 P.M. the Director of Nursing said the following:
-The facility was a non smoking facility;
-She expected staff to complete smoking assessments for safety on all residents upon
admission and at least quarterly;
-The residents were verbally notified upon admission that the facility was non-smoking;
-She was not sure how the facility helped the resident that smoked and were forced to quit
abruptly upon admission;
-The residents were allowed to go outside and smoke with family to get their fix.
During interview on 11/29/18 at 4:34 P.M. the administrator said the following:
-The facility was non smoking for the residents;
-The facility did not have anything in writing to notify perspective resident’s that the
home was non smoking;
-The facility staff along with the individuals that place the residents verbally made
residents aware the facility was non smoking;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/3/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265481

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

PIN OAKS LIVING CENTER

STREET ADDRESS, CITY, STATE, ZIP

1525 WEST MONROE
MEXICO, MO 65265

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0926

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 24)
-Smoking had not been an issue for the last four years and he was going to have to look
into the issue.