Pinewood Manor Assisted Living

The facility failed to ensure that two exit doors had a continuously sounding device engaged that is audible throughout the facility. This is required for residents identified as disoriented or exhibiting wandering behavior, such as Resident #2 who has a diagnosis of dementia. Observations showed the front door alarm did not continuously sound, and the kitchen exit door lacked a continuous sounding device.

The facility failed to ensure that outside entrance doors are equipped with a continuously sounding device that is audible throughout the facility when opened. During the survey, it was observed that the alarm was not audible when doors were opened, which posed a risk to a resident with a diagnosis of dementia.

The facility failed to ensure that exit doors had a continuously sounding device that is activated when the door is opened. This was identified for two exit doors, including one near the kitchen, which is a requirement because a resident with dementia and disorientation resides in the facility.

The facility failed to ensure that two exit doors had a continuously sounding device activated when opened, which is required for residents with dementia or wandering behavior. Specifically, one entrance alarm only sounded during the movement of the door rather than continuously, and a second kitchen exit door lacked a continuous sounding device entirely.

The facility failed to develop a care plan for 3 of 3 sampled residents. For Resident #1, the care plan was incomplete, missing page 3, and lacked required signatures from both the assessor and the Primary Care Physician.

The facility failed to maintain a matching therapeutic diet menu for a resident ordered to be on a 2-gram sodium carbohydrate level diet. While a diabetic menu was posted, there was no regular menu or specific therapeutic menu available for staff guidance.

The facility failed to ensure a nutritional supplement was served as ordered for Resident #1. Despite a physician's order for a nutritional supplement with each meal, the resident had not received supplements since admission in February 2024.

The facility failed to develop complete and individualized resident care plans for 3 of 3 sampled residents. Specifically, the care plans for these residents contained blank pages and, in one instance, lacked required signatures from the assessor and the Primary Care Physician.

The facility failed to ensure that one of three sampled residents had completed the required two-step tuberculosis (TB) skin testing. Specifically, there was no documentation in Resident #3's record indicating that a second TB skin test had been administered following their admission to the facility.

The facility failed to ensure that one of three sampled residents had completed the required two-step tuberculosis (TB) testing. Specifically, there was no documentation of a TB skin test being administered to Resident #3 either before or after their admission to the facility.