Inspection Reports for
Pin Oaks Living Center
1525 WEST MONROE ST, MEXICO, MO, 65265-1201
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
184% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
72% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Deficiencies: 3
Date: Jan 7, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements for nursing staff adequacy, resident rights, and nurse staffing information posting at Pin Oaks Living Center.
Findings
The facility was found deficient in honoring residents' rights to organize and participate in resident/family groups, providing sufficient nursing staff daily including a licensed nurse on each shift, and posting nurse staffing information every day. Deficiency texts were not available for detailed descriptions.
Deficiencies (3)
F 0565: The facility failed to honor the resident's right to organize and participate in resident/family groups.
F 0725: The facility did not provide enough nursing staff every day to meet the needs of every resident and lacked a licensed nurse in charge on each shift.
F 0732: The facility failed to post nurse staffing information every day.
Inspection Report
Routine
Census: 89
Deficiencies: 5
Date: Nov 18, 2025
Visit Reason
Routine inspection of Pin Oaks Living Center to assess compliance with regulatory requirements including resident care, staffing, and treatment standards.
Findings
The facility failed to promptly address Resident Council grievances, follow professional standards for fall injury documentation and physician notification, adhere to wound vac dressing orders resulting in resident harm, provide sufficient nursing staff to meet resident needs, and accurately post nurse staffing information.
Deficiencies (5)
F 0565: The facility failed to act promptly on Resident Council grievances regarding care and quality of life, including call light response times and laundry issues, with no documented follow-up or action plans.
F 0658: The facility failed to complete assessment, documentation, and physician notification for a fall with injury for Resident #10, lacking fall event documentation and physician orders.
F 0684: The facility failed to follow physician orders for biweekly wound vac dressing changes for Resident #11, resulting in sponge adherence to the wound and sternum, requiring urgent surgery and causing extended hospitalization and behavioral health issues.
F 0725: The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in long call light wait times, residents left incontinent and in soiled briefs, and delayed assistance with toileting and transfers.
F 0732: The facility failed to routinely post daily staffing sheets and accurately reflect the number of hours worked by nursing staff, with discrepancies between posted and actual hours worked.
Report Facts
Facility census: 89
Residents requiring mechanical lift: 11
Staffing shortfall: 2
Discrepancy in CNA hours worked: 22
Discrepancy in CNA hours worked: 20.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Named in fall injury documentation deficiency for Resident #10 |
| RN F | Registered Nurse | Interviewed regarding fall injury documentation and neurological checks for Resident #10 |
| RN A | Registered Nurse/Wound Nurse/Educator | Interviewed regarding wound vac dressing orders and care for Resident #11 |
| Director of Nursing | Director of Nursing | Interviewed regarding Resident Council follow-up, fall injury protocols, wound care, and staffing |
| Administrator | Facility Administrator | Interviewed regarding Resident Council issues, wound care policies, staffing, and posted staffing sheets |
| Physician Assistant | Physician Assistant | Provided wound care orders and follow-up for Resident #11 |
| CMT A | Certified Medication Technician | Mentioned in staffing and resident care delays |
| CMT B | Certified Medication Technician | Mentioned in staffing and resident care delays |
Inspection Report
Routine
Census: 71
Deficiencies: 16
Date: Nov 14, 2024
Visit Reason
Routine state inspection survey of Pin Oaks Living Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure proper medication self-administration assessments, incomplete code status documentation, inadequate beneficiary notification, failure to prevent resident abuse and timely report incidents, incomplete care plans, lack of discharge summaries, inconsistent activity programming, inadequate pressure ulcer care, unsafe smoking supervision with oxygen use, incomplete dialysis catheter care orders, improper use and assessment of bed rails, insufficient DON full-time presence, lack of psychotropic medication monitoring, unsecured medication storage, and infection control lapses.
Deficiencies (16)
F 0554: The facility failed to ensure one resident had an assessment and physician order for self-administration of medications, placing the resident at risk for medication errors.
F 0578: The facility failed to ensure code status and advance directives were properly documented and signed by physicians or residents for two residents.
F 0582: The facility failed to properly notify two residents of potential Medicare non-coverage and financial liability.
F 0600: The facility failed to prevent resident-to-resident verbal abuse and did not investigate or report the incidents timely.
F 0610: The facility failed to thoroughly investigate an incident of resident-to-resident verbal abuse involving two residents.
F 0656: The facility failed to develop and implement comprehensive care plans for three residents to address all needs including oxygen use, psychotropic medication, and injury prevention.
F 0661: The facility failed to complete a final discharge summary for one discharged resident, risking continuity of care.
F 0679: The facility failed to implement scheduled activities consistently and failed to provide one resident with activities based on assessed preferences.
F 0686: The facility failed to provide appropriate pressure ulcer care and did not use a pressure reducing cushion on a resident's Broda chair, contrary to manufacturer guidelines.
F 0689: The facility failed to ensure a safe environment for a resident using oxygen while smoking, including lack of staff training and unsecured oxygen tanks near smoking areas.
F 0761: The facility failed to ensure medication carts and medication rooms were locked when unattended and controlled medications were not stored in a double lock manner.
F 0880: The facility failed to maintain infection control during medication administration, failed to change oxygen tubing weekly, and failed to perform proper hand hygiene during wound care.
F 0909: The facility failed to ensure bed rails were physically safe and properly maintained for two residents; rails were loose and not routinely inspected.
F 0700: The facility failed to assess and obtain informed consent for the use of bed rails for two residents.
F 0727: The facility failed to ensure the Director of Nursing served full time and did not serve as charge nurse, potentially impacting nursing administration duties.
F 0758: The facility failed to monitor residents receiving psychotropic medications for behaviors, side effects, and did not obtain informed consent for these medications.
Report Facts
Residents affected: 71
Residents reviewed: 24
Controlled medication cards unsecured: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1/UM | Licensed Practical Nurse/Unit Manager | Confirmed medication cart unlocked, bed rail assessments, and medication storage issues |
| DON/IP | Director of Nursing/Infection Preventionist | Interviewed regarding multiple deficiencies including infection control, psychotropic medication monitoring, and DON role |
| Administrator | Interviewed regarding facility policies, training, and expectations for medication security and infection control | |
| LPN2 | Licensed Practical Nurse | Observed medication administration with bare hands |
| CMT3 | Certified Medication Technician | Observed unlocked medication room and confirmed policy |
| Maintenance Director | Confirmed loose bed rails and smoking area oxygen safety concerns |
Inspection Report
Life Safety
Census: 72
Capacity: 124
Deficiencies: 2
Date: Nov 12, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with life safety code requirements related to egress doors and electrical wiring. Specific deficiencies included delayed egress locking hardware not unlocking properly and unsecured flexible metal conduit wiring near an electrical panel.
Deficiencies (2)
K222 Egress Doors: The facility failed to ensure three of ten egress doors equipped with delayed egress locking hardware unlocked and opened when pressure was applied, affecting all 69 residents.
K511 Utilities - Gas and Electric: The facility failed to ensure wiring maintained in flexible metal conduit exiting an electrical panel was secured within 12 inches of the panel, posing a safety hazard.
Report Facts
Residents affected: 69
Facility capacity: 124
Census: 72
Egress doors inspected: 10
Egress doors deficient: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittney Allen | Administrator | Signed the inspection report and plan of correction |
| Maintenance Director | Interviewed regarding egress door and wiring deficiencies |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 6
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property and medication discrepancies at Pin Oaks Living Center.
Complaint Details
The complaint investigation was substantiated. The facility was found to have missing medications for one resident and failures in medication count verification and storage. Staff interviews and record reviews confirmed discrepancies and policy violations.
Findings
The facility failed to protect residents from misappropriation of property when medications were found missing for one resident. Licensed staff failed to complete accurate narcotic counts and follow facility policies for medication storage and verification.
Deficiencies (6)
F602: The facility failed to protect residents from misappropriation of property when 40 tablets of oxycodone/acetaminophen and 5 tablets of gabapentin were missing for one resident. Licensed staff did not complete accurate narcotic counts or follow medication policies.
F761: The facility failed to ensure narcotic counts were completed to detect missing doses, failed to label medications properly, and failed to store medications securely. Licensed staff did not follow policies for accepting medications brought from home.
A4055: The facility did not maintain a safe and effective system of medication distribution, administration, control, and use. This deficiency was classified as Class II due to the extent of the violation.
A4063: The facility failed to ensure resident medications brought to the facility were examined, identified, and documented by a pharmacist or physician. This deficiency was classified as Class II.
A4071: The facility failed to establish an accurate system of records for receipt and disposition of controlled drugs. Records were not maintained or reconciled properly. This deficiency was classified as Class II.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents, including misappropriation of property. This deficiency was classified as Class II.
Report Facts
Resident census: 68
Missing oxycodone/acetaminophen tablets: 40
Missing gabapentin tablets: 5
Original narcotic count: 338
Gabapentin capsules: 184
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding suspected misappropriation of resident property and medication discrepancies involving controlled substances for one resident.
Complaint Details
The investigation was substantiated. The facility confirmed missing controlled medications for Resident #1 and identified failures in medication count verification, labeling, storage, and acceptance policies.
Findings
The facility failed to protect a resident from misappropriation of medications, specifically oxycodone/acetaminophen and gabapentin, which were found missing. The facility also failed to ensure proper narcotic counts at shift changes, proper labeling, and verification of medications brought from home, violating facility policies and federal guidelines.
Deficiencies (2)
F0602: The facility failed to protect residents from misappropriation of property when 40 tablets of oxycodone/acetaminophen and five tablets of gabapentin were missing for one resident. Staff failed to properly count and document controlled medications at shift changes.
F0761: The facility failed to ensure narcotic counts were completed at shift changes, failed to label medications properly, and failed to store medications securely. Staff did not verify medications brought from home with a pharmacist or physician as required.
Report Facts
Residents present: 68
Missing oxycodone/acetaminophen tablets: 40
Missing gabapentin tablets: 5
Initial oxycodone/acetaminophen tablets counted: 338
Initial gabapentin tablets counted: 271
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Counted medications on admission, administered medications, and interviewed regarding medication handling |
| CMT B | Certified Medication Technician | Counted medications on admission, administered medications, found missing medications, and interviewed |
| CMT C | Certified Medication Technician | Administered medications, divided gabapentin into unlabeled bags, failed to count narcotics at shift change, and interviewed |
| RN D | Registered Nurse | Oncoming charge nurse who routinely refused to count narcotics at shift change and interviewed |
| Director of Nursing | Director of Nursing (DON) | Conducted medication counts during investigation and interviewed regarding policy compliance |
| Administrator | Facility Administrator | Interviewed regarding facility policies and expectations for medication handling and verification |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 2
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with resident rights and dignity regulations at Pin Oaks Living Center.
Findings
The facility failed to ensure staff treated residents with dignity and respect, as evidenced by verbal abuse and neglectful behavior toward residents #7, #8, and #9. Multiple interviews and record reviews confirmed inappropriate staff conduct and failure to meet residents' needs.
Deficiencies (2)
F 557: The facility failed to treat residents with respect and dignity, including verbal abuse and neglect of residents #7, #8, and #9. Staff used disrespectful language and failed to assist residents appropriately.
A8030: Each resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care. This regulation was not met as evidenced by F557.
Report Facts
Resident census: 71
Residents identified: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Ellis | Administrator | Signed the statement of deficiencies and plan of correction |
| CNA B | Named in multiple findings related to disrespectful behavior and neglect of residents | |
| CNA D | Reported observations of CNA B and CNA E behavior | |
| Licensed Practical Nurse C | Licensed Practical Nurse (LPN) | Reported on staff behavior and responsibilities regarding resident care |
| Interim Director of Nursing | Director of Nursing (DON) | Provided statements regarding staff conduct and expectations |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 1
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to complaints regarding staff failing to treat residents with dignity and respect, including verbal abuse and neglect of assistance requests.
Complaint Details
The complaint was substantiated. Staff were found to have verbally abused residents #7, #8, and #9, including name-calling, rude comments, ignoring call lights, and disrespectful behavior.
Findings
The facility failed to ensure staff treated three residents with dignity and respect. Staff were verbally rude, disrespectful, and neglectful in responding to residents' needs, including inappropriate language and failure to assist with care.
Deficiencies (1)
F 0557: The facility failed to ensure staff treated residents with respect and dignity, including calling a resident a fatty, using cuss words in residents' presence, ignoring call lights, and making disrespectful comments about residents' hygiene and rooms.
Report Facts
Facility census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nurse Aide | Named in multiple findings for verbal abuse, disrespectful comments, ignoring call lights, and cussing in presence of residents |
| CNA E | Certified Nurse Aide | Mentioned for refusing to assist resident on the floor and cussing in presence of residents |
| CNA D | Certified Nurse Aide | Witnessed CNA B and CNA E's behavior and reported cussing and refusal to assist residents |
| LPN C | Licensed Practical Nurse | Reported knowledge of CNA B's disrespectful behavior and counseled CNA B |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding expectations for staff behavior and unawareness of CNA B's actions |
| Administrator | Administrator | Interviewed regarding expectations for staff behavior and unawareness of CNA B's actions |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Jul 19, 2023
Visit Reason
The inspection was conducted due to an allegation of verbal abuse by a nurse aide towards a resident, reported after the incident occurred on 7/3/23.
Complaint Details
The complaint involved verbal abuse by Nurse Aide (NA) A towards Resident #1 on 7/3/23 between 8:30 P.M. and 10:00 P.M. Two staff members witnessed the abuse but did not report it. The facility reported the allegation to the state agency on 7/4/23 at 3:00 P.M. NA A was terminated following the investigation.
Findings
The facility failed to ensure one resident was free from verbal abuse by a nurse aide who yelled and cursed at the resident. Additionally, the facility failed to report the allegation of abuse to the state agency within the required two-hour timeframe.
Deficiencies (2)
F 0600: The facility failed to protect a resident from verbal abuse by a nurse aide who yelled, cursed, and made derogatory remarks to the resident. The nurse aide was terminated after the investigation.
F 0609: The facility failed to timely report an allegation of verbal abuse to the state agency within two hours as required. The abuse occurred on 7/3/23 but was reported on 7/4/23 at 3:00 P.M.
Report Facts
Facility census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Alleged perpetrator of verbal abuse |
| NA B | Nurse Aide | Witness to the verbal abuse incident |
| NA C | Nurse Aide | Witness to the verbal abuse incident |
| CNA D | Certified Nurse Aide | Reported the abuse to administration |
| Director of Nursing | Director of Nursing | Conducted interviews and initiated investigation |
| Administrator | Administrator | Authorized suspension and termination of NA A |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 63
Deficiencies: 4
Date: Jun 13, 2023
Visit Reason
The inspection was conducted due to allegations of verbal abuse by a nurse aide towards a resident and concerns about the facility's reporting and investigation of abuse and missing resident property.
Complaint Details
The complaint involved verbal abuse by Nurse Aide A towards Resident #1, witnessed by two staff members. The facility delayed reporting the abuse to the state agency beyond the required two-hour timeframe. Additionally, there was a complaint about missing money from Resident #17's purse, and the facility failed to conduct a thorough investigation. The complaint also included concerns about inadequate care related to a resident's PICC line.
Findings
The facility failed to protect a resident from verbal abuse by a nurse aide, failed to timely report the abuse allegation to the state agency, failed to conduct a thorough investigation of missing resident money, and failed to obtain physician orders for care and maintenance of a resident's PICC line.
Deficiencies (4)
F 0600: The facility failed to ensure one resident was free from verbal abuse when a nurse aide yelled, cursed, and intimidated the resident. The nurse aide was terminated after investigation.
F 0609: The facility failed to report an allegation of verbal abuse to the state agency within two hours as required, delaying the report until the next day.
F 0610: The facility failed to conduct a thorough investigation of missing money reported by a resident's family, including failure to interview all relevant staff and clarify discrepancies.
F 0658: The facility failed to obtain physician orders for the care and maintenance of a resident's PICC line, including flushes and dressing changes, and lacked a PICC line policy.
Report Facts
Facility census: 62
Facility total capacity: 63
Date of abuse incident: Jul 3, 2023
Date abuse reported: Jul 4, 2023
Missing money amount: 60
Dates of antibiotic administration: 2023-05-24 to 2023-06-02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Alleged perpetrator of verbal abuse towards Resident #1 |
| NA B | Nurse Aide | Witness to verbal abuse incident |
| NA C | Nurse Aide | Witness to verbal abuse incident |
| CNA D | Certified Nurse Aide | Reported verbal abuse incident to administration |
| Director of Nursing | Director of Nursing | Conducted investigation and suspended NA A |
| LPN D | Licensed Practical Nurse | Witnessed staff entering resident's room during missing money investigation |
| NA M | Nurse Aide | Alleged perpetrator in missing money investigation |
| Administrator | Facility Administrator | Directed suspension and investigation of NA A and handled missing money report |
| RN C | Registered Nurse | Provided information on PICC line order expectations |
| RN N | Registered Nurse | Responsible for resident medication upon admission; did not obtain PICC line order |
| LPN L | Licensed Practical Nurse | Provided information on PICC line order and care requirements |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Date: Mar 29, 2023
Visit Reason
The investigation was triggered by notification from the local police that nerve pain medication (gabapentin) belonging to two residents was found at a certified medication technician's home, indicating possible misappropriation of residents' property.
Complaint Details
The complaint was substantiated based on interviews, record reviews, and evidence that medications belonging to two residents were found at a staff member's home. The staff member was terminated. The facility lacked proper medication destruction and tracking procedures.
Findings
The facility failed to protect two residents from misappropriation of their medications and lacked a system to properly log, track, and destroy medications that were discontinued, returned, or sent home with residents. Documentation for destruction or return of medications was incomplete or missing.
Deficiencies (2)
F 0602: The facility failed to protect two residents from misappropriation of their nerve pain medication found at a staff member's home. The facility census was 67.
F 0761: The facility failed to have a system to log and track medications to be destroyed, returned, or sent home, resulting in missing documentation for destruction or return of medications for two residents. The facility census was 67.
Report Facts
Facility census: 67
Missing gabapentin pills: 35
Undocumented medication quantities: 88
Undocumented medication quantities: 5
Undocumented medication quantities: 9
Undocumented medication quantities: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT E | Certified Medication Technician | Named in misappropriation of residents' medications finding; terminated from employment |
| Administrator | Provided statements regarding medication policies and staff expectations | |
| DON | Director of Nursing | Responsible for supervising medication destruction and reviewing pharmacy reports |
| Medical Director | Commented on legal expectations for medication documentation |
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 6
Date: Mar 29, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to resident abuse, medication management, and regulatory compliance at Pin Oaks Living Center.
Findings
The facility was found not free from misappropriation/exploitation of resident property and failed to properly label, store, and track medications. Documentation and destruction of medications were inadequate, and policies to prevent abuse and neglect were insufficient.
Deficiencies (6)
F602: The facility failed to ensure two residents remained free from misappropriation of property, including missing nerve pain medication found in a certified med technician's home. The facility census was 67.
F761: The facility failed to have a system to log and track residents' medications that were to be destroyed, returned, or sent home, as evidenced by missing documentation and unaccounted medications for two residents.
A4068: Medications shall be destroyed by a pharmacist and a licensed nurse or two licensed nurses. This regulation was not met as evidenced by Class III deficiency related to F761.
A4069: Facilities shall maintain records of medication destruction including resident name, date, medication details, and signatures. This was not met as evidenced by Class III deficiency related to F761.
A4070: Facilities shall maintain records of medication released to family or pharmacy upon discharge. This was not met as evidenced by Class III deficiency related to F761.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, including reporting requirements. This was not met as evidenced by Class II* deficiency related to F602.
Report Facts
Facility census: 67
Medication quantities: 90
Medication quantities: 60
Medication quantities: 30
Medication quantities: 23
Medication quantities: 8
Medication quantities: 43
Inspection Report
Routine
Census: 67
Deficiencies: 15
Date: Feb 23, 2023
Visit Reason
Routine inspection of Pin Oaks Living Center to assess compliance with healthcare regulations including resident care, safety, and facility conditions.
Findings
The inspection identified multiple deficiencies including failure to ensure call lights were within reach for residents, lack of proper notification for Medicare non-coverage and transfers, inadequate maintenance and cleanliness of the facility, improper use of restraints, failure to provide timely bed hold and transfer notices, medication administration errors, inadequate personal hygiene care, unsafe resident transfers, improper catheter and respiratory care, poor infection control practices, and failure to implement trauma-informed care.
Deficiencies (15)
F 0558: Facility failed to ensure call lights were within reach for two residents, compromising their ability to summon assistance.
F 0582: Facility failed to provide required Medicare non-coverage notices to two residents upon discharge from Medicare services.
F 0584: Facility failed to maintain exhaust vents, lighting, heating/ventilation units, walls, ceilings, and flooring in good repair and free of debris, creating unsanitary conditions.
F 0604: Facility failed to evaluate one resident's wheelchair as a restraint and lacked documentation of medical necessity or physician orders for restraint use.
F 0623: Facility failed to provide written notice of transfer/discharge to residents or their representatives for five residents transferred to hospital.
F 0625: Facility failed to provide written notice of bed hold policy to residents or representatives for five residents transferred to hospital.
F 0658: Facility failed to follow physician orders for one resident by not administering ordered potassium and not obtaining ordered lab tests after hospital return.
F 0677: Facility failed to provide necessary personal hygiene care including bathing and shaving for three residents requiring assistance.
F 0686: Facility failed to provide appropriate pressure ulcer care for one resident by not using heel protectors while in bed.
F 0689: Facility failed to ensure safe transfers for three residents, including failure to use gait belts and footrests on wheelchairs.
F 0690: Facility failed to provide proper catheter care for one resident by allowing catheter tubing and drainage bag to touch the floor, and failed to maintain respiratory equipment properly for two residents.
F 0695: Facility failed to provide safe and appropriate respiratory care for four residents, including failure to maintain oxygen equipment, provide ordered oxygen therapy, and clean respiratory supplies.
F 0699: Facility failed to implement trauma informed care for one resident with PTSD and history of suicidal ideations, lacking trauma-specific interventions and support.
F 0812: Facility failed to ensure dietary staff wore hairnets properly during food preparation and service.
F 0880: Facility failed to ensure staff washed hands and changed gloves appropriately during personal care, failed to maintain infection control during wound care and respiratory care, and failed to complete required tuberculosis skin testing for employees.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 5
Residents affected: 5
Residents affected: 3
Residents affected: 3
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees affected: 4
Inspection Report
Routine
Census: 76
Deficiencies: 12
Date: Aug 9, 2019
Visit Reason
Routine inspection of Pin Oaks Living Center to assess compliance with regulatory requirements including resident rights, environment, care planning, staffing, infection control, and food service.
Findings
The facility was found deficient in multiple areas including failure to promptly address resident council grievances, inadequate posting of survey results, environmental maintenance issues, failure to inform residents of bed hold policies, incomplete and outdated care plans, failure to follow physician orders especially related to oxygen therapy, inadequate assistance with activities of daily living, unsafe resident transfers, insufficient staffing, serving food at improper temperatures, failure to provide bedtime snacks, and lapses in infection control practices.
Deficiencies (12)
F 0565: Facility failed to act promptly on resident council grievances and failed to provide responses to concerns including staffing, care, laundry, and housekeeping.
F 0577: Facility failed to prominently post survey results, complaint investigation findings, and plans of correction in accessible locations for residents and families.
F 0584: Facility failed to maintain floors and walls in good repair and failed to maintain comfortable temperatures in resident areas.
F 0625: Facility failed to inform residents and representatives of bed hold policy at time of hospital transfer for three residents.
F 0657: Facility failed to develop and update care plans consistent with residents' conditions, including one resident whose care plan did not reflect current status.
F 0658: Facility failed to follow physician orders for oxygen administration and diet consistency for three residents, including failure to provide oxygen as ordered and serving non-thickened liquids.
F 0677: Facility failed to provide adequate personal and oral hygiene care to multiple residents, including improper perineal care and failure to provide oral care.
F 0689: Facility failed to provide adequate supervision to prevent one resident from wandering outside the facility and failed to safely transfer three residents, including improper use of gait belts and stand-up lifts.
F 0725: Facility failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed assistance, missed cares, and inadequate supervision.
F 0804: Facility failed to ensure food was served at safe and appetizing temperatures; observed food temperatures were below 120 degrees Fahrenheit.
F 0809: Facility failed to offer residents a daily bedtime snack and failed to document snack intake or refusal.
F 0880: Facility failed to ensure staff washed hands appropriately and prevented cross-contamination during personal care and linen handling.
Report Facts
Facility census: 76
Number of residents sampled: 22
Food temperature: 92
Food temperature: 94
Food temperature: 112
Food temperature: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Named in oxygen administration and resident care findings |
| Certified Nurse Assistant B | Certified Nurse Assistant | Named in resident care, hygiene, and infection control findings |
| Nurse Assistant D | Nurse Assistant | Named in resident care, hygiene, and infection control findings |
| Certified Nurse Assistant F | Certified Nurse Assistant | Named in resident care and infection control findings |
| Certified Nurse Assistant N | Certified Nurse Assistant | Named in resident care and transfer findings |
| Certified Nurse Assistant Q | Certified Nurse Assistant | Named in resident transfer findings |
| Nurse Assistant R | Nurse Assistant | Named in resident care and oral care findings |
| Certified Medication Technician O | Certified Medication Technician/Transporter | Named in resident elopement incident |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple findings including staffing, care, and elopement |
| Administrator | Administrator | Interviewed regarding staffing and elopement incident |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and snack service |
| Activity Director | Activity Director | Interviewed regarding resident council and nail care |
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