PIN OAKS LIVING CENTER

**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;

**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;

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

-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.

**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

**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];

**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.

**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

**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:

**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:

**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

**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

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