Adviniacare Oakland Grove LLC

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that an accident resulting in hospital admission was reported to the appropriate authorities, including the State Survey Agency, as required by state law, for 1 of 1 resident reviewed who sustained a fall and was admitted to the hospital as a result, Resident ID #2.

Inspectors wroteBased on record review, surveyor observations, staff and resident interviews, the facility failed to provide an environment that remained as free of accident hazards as possible and failed to implement adequate supervision and interventions to prevent avoidable harm. Specifically, the facility failed to ensure safe water temperatures in resident-accessible hand sinks throughout all four resident care floors, exposing residents to the potential for serious burn injuries. In addition, the facility failed to ensure that Resident ID #2 received timely and appropriate post-fall assessment, monitoring, and interventions in accordance with facility policy following a fall, placing the resident at risk for undetected injury and potential worsening of condition.

Inspectors wroteBased on clinical record review, surveyor observation, and resident and staff interviews, the facility failed to immediately consult with the physician when a resident's condition significantly changed or when treatment required alteration for 2 of 2 residents reviewed, Resident ID #1 and #5. The facility failed to notify the practitioner of Resident ID #1's worsening respiratory status, fever, lethargy, and labored breathing while receiving hospice services, and failed to obtain a physician order or notify the practitioner regarding Resident ID #5's urinary retention requiring catheterization. These failures had the potential to delay medical evaluation and treatment and resulted in actual harm for Resident ID #5, who required hospitalization for urinary retention.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide care and services in accordance with the resident's physician-approved hospice plan of care for 1 of 1 resident reviewed receiving hospice services, Resident ID #1. Specifically, the facility failed to ensure timely administration of physician-ordered Morphine Sulfate for the management of pain and shortness of breath despite repeated hospice recommendations, worsening clinical symptoms, and the medication being available within the facility. As a result, Resident ID #1 experienced prolonged unmanaged pain and respiratory distress, including worsening lethargy, labored breathing, tachypnea (rapid shallow breathing), tachycardia (rapid heart rate), and fever.

Inspectors wroteBased on surveyor observation, staff interview, and clinical record review, the facility failed to ensure appropriate foot care was provided and arranged for 1 of 1 resident observed with overgrown toenails, Resident ID #2.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide specialized dialysis care in accordance with professional standards of practice and the facility's policy by failing to monitor and document the patency of a newly placed Arteriovenous (AV) fistula (a surgically created connection between an artery and a vein that allows blood to flow directly from the artery into the vein, bypassing capillaries) for 1 of 1 resident reviewed, Resident ID #6.

Inspectors wroteBased on surveyor observation and staff interview, the facility failed to provide and maintain a sanitary, safe, and comfortable environment by allowing the accumulation of extensive black and brown buildup throughout 3 of 3 communal shower rooms observed.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician's orders for 1 of 1 resident observed for enteral nutrition tube feeding, (a delivery of nutrition into the stomach or small intestine via an enteral access device), Resident ID #2.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident relative to urinary catheter (a flexible tube inserted into the bladder to empty urine) use, gastrostomy (g tube; a surgically created opening through the abdominal wall into the stomach to allow for nutrition or medications) tube care, thickened liquids, and dialysis (a treatment to remove extra fluid and waste when kidneys can no longer do so adequately) for 5 of 5 licensed staff reviewed, Staff E, M, P, Q, and R.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents reviewed relative to end of life care, Resident ID #1.

Inspectors wroteBased on surveyor observation, staff interview, and clinical record review, the facility failed to ensure food and fluids were provided in a modified form designed to meet the individual clinical needs for 1 of 1 resident reviewed for therapeutic diets, Resident #7.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to adhere to its established bowel management protocol by not initiating timely interventions after 9 consecutive shifts without a bowel movement, failing to notify the provider of medication refusal and a new diagnosis of constipation, and neglecting to reassess and update the care plan. These failures resulted in prolonged fecal impaction, hospitalization, and contributed to the Resident's clinical deterioration and death. This deficient practice was identified in 1 of 3 residents reviewed for bowel management, Resident ID #1.

Inspectors wroteBased on surveyor observation and staff interview, the facility failed to maintain all mechanical, electrical, and patient care equipment, in a safe operating condition for the walk-in freezer unit in the main kitchen.

Inspectors wroteBased on record review and staff interview, the facility failed to meet professional standards of quality for 1 of 1 resident reviewed with a physician's order for a neck brace, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that all residents receive treatment and care in accordance with professional standards, relative to follow up physician appointments for 2 of 2 residents reviewed, Resident ID #s 11 and 85.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free of any significant medication errors for 1 of 2 residents reviewed for antibiotics, Resident ID #85, 1 of 2 residents reviewed for pain management, Resident ID #82, and 1 of 1 resident reviewed for divalproex sodium (Depakote, a medication prescribed for off-label use to manage agitation and other challenging behaviors in dementia patients), Resident ID #30.

Inspectors wroteBased on surveyor observation, record review, staff, resident, and resident representative interview, it has been determined that the facility failed to ensure each resident is treated with respect and dignity relative to 2 of 3 residents reviewed who required staff assistance for incontinence, Resident ID #s 2 and 90.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to implement a comprehensive person-centered care plan for each resident relative to urinary catheters for 1 of 3 residents reviewed, Resident ID #16.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 2 residents observed for wound care, Resident ID #14.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles for 1 of 3 floors observed, the 3rd floor.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to keep a resident free from physical abuse, for 1 of 4 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to 1 of 1 resident reviewed for a splint, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to honor a resident's right to request treatment for 1 of 1 resident reviewed for a hospital transfer, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, relative to following physician orders for antibiotic therapy and an for monitoring the output of an indwelling foley catheter (a device that drains urine from your urinary bladder into a collection bag outside of your body when you can't urinate on your own), for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections, relative to Enhanced Barrier Precautions (EBP; involves using a gown and gloves during high-contact resident care activities), an enteral feeding (a method of delivering nutrition directly into the gastrointestinal tract through a feeding tube) syringe and the storage of a nebulizer mask, for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to maintain the resident's medical record in accordance with accepted professional standards and practices, for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from significant medication errors for 1 of 1 resident reviewed who was administered antipsychotic medication (Clozaril) which was intended for another resident (Resident ID #2), Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to evaluating a resident after a suspected medication error occurred for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 5 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that allegations made by residents are recognized as possible abuse by staff, all allegations are investigated, and that residents are kept free from experiencing further abuse during investigations for 1 of 1 Resident reviewed who expressed concerns to staff members regarding a consensual sexual relationship with another resident, Resident ID #1 (the alleged victim).

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections by failing to implement appropriate precautions, documentation of follow-up activity in response and comply with state and local public health authority requirements for identification, reporting, and containing communicable diseases and outbreaks. Furthermore, the facility failed to don [put on] the required Personal Protective Equipment (PPE) prior to entering resident rooms that required precautions for 1 of 2 units reviewed.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice relative to following physicians' orders for 4 of 4 residents reviewed for intake and output (I&O), Resident ID #s 26, 30, 61, and 104.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight, for 3 of 6 residents reviewed for significant weight loss and/or gain, Resident ID #s 76, 96, and 104.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care, in accordance with professional standards of practice and accounting for residents' experiences and preferences, in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident reviewed, relative to a resident with history of post traumatic stress disorder (PTSD), Resident ID #96.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents who are fed by a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed relative to a gastrostomy tube (G-tube, which is a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine), Resident ID #76.

Inspectors wroteBased on record review, and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed for the use of Humira (a medication used to treat rheumatoid arthritis), Resident ID #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan relative to monitoring and identifying a change in a resident's condition. Additionally, the facility failed to follow physician's orders relative to weekly weights, for 1 of 1 resident reviewed who exhibited increased swelling to his/her left leg and was diagnosed with a deep vein thrombosis (DVT- a blood clot). Resident ID #1.

Inspectors wroteBased on surveyor observation, record review and staff interview it has been determined that the facility failed to protect and keep residents free from physical abuse relative to an incident that occurred between Resident ID #1 and Resident ID #5.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections for 1 of 1 resident reviewed for the management of a Multidrug-resistant Organism (MDRO), Resident ID #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep a resident free from sexual abuse for 1 of 1 resident reviewed, Resident ID #4 and for 1 of 2 residents reviewed for physical abuse, Resident ID #2.

Inspectors wroteBased on record review, resident, and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made to the State Agency in accordance with State law for 1 of 1 resident reviewed for sexual abuse, Resident ID #4.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of a resident's admission, that includes the instructions needed to provide effective and person-centered care for 1 of 1 resident reviewed with inappropriate sexual behaviors, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen and for 3 of 3 unit kitchenettes observed.

Inspectors wroteBased on record review, resident, and staff interview, it has been determined that the facility failed to ensure that all alleged violations involving abuse, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to other officials (Department of Health), in accordance with State law for 1 of 1 resident reviewed for misappropriation, and 1 of 1 resident reviewed for injury of unknown origin, Resident ID #s 7 and 20.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to meet professional standards of quality relative to physician's orders, for 1 of 2 residents with recommendations from an outside consultant, Resident ID #35, 1 of 7 residents reviewed for medication administration, Resident ID #107, 4 of 13 residents with an air mattress, Resident ID #s 11, 58, 73, and 102, and 1 of 1 resident observed during a wound treatment, Resident ID# 88.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living (ADL's) do not diminish unless circumstances of the individual's clinical condition demonstrate that such a diminution was unavoidable, relative to transfer, ambulation, toileting and incontinence care for 1 of 4 residents reviewed, Resident ID# 9.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to provide the necessary services to a resident who is unable to carry out activities of daily living (ADLs), relative to showers for 2 of 4 residents reviewed, Resident ID #s 35 and 73.

Inspectors wroteBased on record review, resident and staff interview, it has been determined that the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 7 residents reviewed for positioning, Resident ID #73.

Inspectors wroteBased on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure residents that are fed through a feeding tube receive the appropriate treatment and services to prevent complications for 1 of 2 residents reviewed who receive nutrition via a feeding tube, Resident ID #85.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services that are in accordance with professional standards of practice for 2 of 2 residents reviewed for respiratory care, Resident ID #s 10 and 41.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility has failed to ensure that residents are free of any significant medication errors for 1 of 7 residents reviewed relative to medication administration, Resident ID #103.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 1 resident observed to have their call light placed out of their reach, Resident ID #23.