Pin Oaks Living Center

In the surveyor’s words

From the most serious findings on record at Pin Oaks Living Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jul 12, 2022

  Based on interview and record review, the facility failed to ensure two residents (Resident #1 and #2) of seven sampled residents, received medications as ordered by their physicians. The facility failed to administer three doses of an anti-seizure medication to Resident #1. The resident experienced seizures following the missed doses of medication and required hospitalization . The facility also failed to follow physician medication orders including daily administration of an antibiotic following surgery for Resident #2. The resident's surgical incision deteriorated with increased drainage and odor and required hospitalization for wound care and intravenous antibiotics. The facility census was 65. The administrator was notified on 7/1/22 at 10:30 A.M. […]

• Immediate jeopardy, isolatedF678May 6, 2021

  Based on interview and record review, the facility failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR; an emergency procedure that is performed when a person's heartbeat or breathing has stopped) in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to perform CPR and upon police arrival, they were the ones to initiate CPR on the full code resident. The facility census was 61. The administrator was notified on [DATE] at 2:20 P.M. of the Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by the surveyor onsite verification. Review of the American Heart Association, Emergency treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Signs of [CONDITION(S)]: -Sudden loss of responsiveness. […]

• Actual harm, isolatedF684Nov 18, 2025

  Based on interview and record review, the facility failed to follow physician orders for surgical wound care for one resident (Resident #11), of nine sampled residents. The facility failed to change the resident's wound vacuum assisted closure (vac) dressing (a specialized sealed foam bandage connected to a portable pump that applies gentle, constant suction to the wound) biweekly per the physician's order. As a result, the wound vac sponge adhered to the wound bed and the sternum (breastbone) requiring surgery for urgent wound debridement (the process of removing dead or damaged tissue from a wound) and omental flap mobilization and skin grafting (a reconstructive surgery technique used to cover large, complex or infected tissue defects, particularly on the chest wall using fatty tissue… […]

• Actual harm, isolatedF725Nov 18, 2025

  Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of four residents (Resident #2, #3, #4 and #1) in a review of 10 sampled residents to answer call lights and check and change residents in a timely manner. Resident #2, normally continent of bowel and bladder, and requiring staff assistance to use the bathroom, turned on his/her call light and requested staff assist him/her out of bed as he/she needed to use the bathroom. Staff did not respond for three hours, and the resident was incontinent of bladder and bowel. The resident laid in urine and feces. […]

• Actual harm, isolatedF600Jun 13, 2023

  Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from abuse when nurse aide (NA) A yelled and cursed at the resident. The facility census was 62. Review of the facility Abuse Prevention Policy and Procedure Checklist, undated, showed the following: -The resident has the right to be free from abuse by anyone; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. […]