A list of the most recent deficiencies for Pin Oaks Living Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-19 | 2023-08-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-19 | 2023-08-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-13 | 2023-08-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-13 | 2023-08-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-13 | 2023-07-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-13 | 2023-07-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-29 | 2023-04-18 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-03-29 | 2023-04-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-23 | 2023-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-23 | 2023-04-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-23 | 2023-04-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-23 | 2023-04-10 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-23 | 2023-04-10 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-02-23 | 2023-04-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-23 | 2023-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-02-23 | 2023-04-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-23 | 2023-04-10 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Meet other general requirements. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-23 | 2023-04-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-12 | 2022-08-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-04 | 2022-03-10 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-04 | 2022-03-10 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-05-06 | 2021-05-08 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-08-09 | 2019-10-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-08-09 | 2019-10-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-08-09 | 2019-10-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-08-09 | 2019-10-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-09 | 2019-10-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-09 | 2019-10-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-09 | 2019-10-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-09 | 2019-10-10 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-09 | 2019-10-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-08-09 | 2019-10-10 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-08-09 | 2019-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-09 | 2019-10-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-09 | 2019-10-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-29 | 2019-02-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-11-29 | 2019-01-10 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-11-29 | 2019-01-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-29 | 2019-01-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-11-29 | 2019-01-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-29 | 2019-01-10 | N |
| 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. | Health | 2018-11-29 | 2019-01-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-29 | 2019-01-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-11-29 | 2019-01-10 | N |
| Have policies on smoking. | Health | 2018-11-29 | 2019-01-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-29 | 2019-01-10 | N |
