The Enclave at Pinedale

The facility failed to ensure that 3 of 3 sampled residents were tested for tuberculosis disease upon admission. Record reviews showed no documentation of the required TB skin tests for these residents in compliance with public health control measures.

The facility failed to ensure that three sampled residents were properly tested for tuberculosis disease upon admission. Specifically, one resident had no documentation of a TB skin test, and another lacked documentation of a required two-step TB skin test.

The facility failed to ensure a resident who eloped and fell outside was sent to the hospital for evaluation in a timely manner and failed to notify the primary care provider when the resident complained of pain. Evidence showed a significant delay between the incident and the EMS call, and a neighbor had to enter the unlocked facility to seek help for the resident.

The facility failed to ensure a resident who eloped and fell outside was sent to the hospital for evaluation in a timely manner and failed to notify the primary care provider when the resident complained of pain. Evidence showed a significant delay between the incident and EMS arrival, and the resident suffered serious injuries including a femoral fracture.

The facility failed to ensure that a care plan and assessment were completed within 30 days of admission for two of the three sampled residents. The assessments were not completed in a timely manner following the residents' admission to the community.

The facility failed to ensure that one of three sampled residents had been tested for Tuberculosis (TB) disease. Specifically, there was no record of tuberculosis surveillance screening or a chest X-ray for Resident #3.