Five Oaks Rehabilitation and Care Center

Inspectors wroteBased on observations, record review and Resident Representative (RR) and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EBP) by not wearing personal protective equipment (PPE) when providing high contact care for a resident with a peripherally inserted central catheter (PICC) line (flexible tube placed in a vein to administer medications) (Resident #7), a resident with a feeding tube (Resident #18), and a resident with a chronic pressure ulcer (Resident #24). This deficient practice occurred for 5 of 15 staff members observed for infection control practices (Nurse #1, Nurse #3, Nurse #4, Nurse Aide (NA) #1 and NA #3).

Inspectors wroteBased on observations and staff interviews, the facility failed to remove expired medications stored in 2 of 3 medication rooms and 1 of 7 medication carts reviewed for medication storage (Medication Rooms for 200 and 300 halls and Medication Cart #3).

Inspectors wrote2. Resident #138 was admitted to the facility on [DATE] with diagnoses which included hypertension, muscle weakness and Alzheimer's disease. Review of Resident #138's most recent significant change Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and was dependent on staff for all activities of daily living (ADL). Review of Resident #138's Care Area Assessment summary dated 01/14/25 revealed she was at risk for falls related to unsteady gait and muscle weakness. Staff will provide transfers as needed. The resident is at risk of a decline in activities of daily living (ADL) related to acute illness and muscle weakness. Nursing staff will provide assistance with ADL as needed. The resident is at risk of altered communication related to cognitive impairment. Staff will anticipate needs and provide assistance as needed. [...]

Inspectors wroteBased on observations, record review, staff, Medical Director, and Wound Care Physician interviews, the facility failed to recognize a developing pressure ulcer, implement preventative measures, provided treatments as ordered, and consistently measure a resident's wounds on a weekly basis. The facility failed to have a Wound Care Provider evaluate residents at the facility when the Wound Care Physician was on vacation for 1 of 3 residents (Resident #59) reviewed for facility acquired pressure ulcers. On 11/20/24 Resident #59 developed discoloration to the coccyx area which developed to unstageable pressure ulcer on 12/06/24 that required a debriding agent (removal of dead tissue). The wound further required antibiotic treatment for infection, treatment using non-contact, non-thermal, low frequency ultrasound and physical debridement of the wound on 02/19/25.

Inspectors wroteBased on observations, record review, and staff, Resident, Medical Director, and Wound Care Physician interviews, the facility failed to ensure a resident with an unstageable pressure ulcer that required wound debridement (removal of dead tissue) had her pain controlled prior to attempted weekly wound debridement for 8 weeks and the facility failed to address a resident's pain after she had experienced pain with wound dressing changes for 1 of 3 residents (Resident #59) reviewed for pain management. On 12/11/24, 12/18/24, 01/01/25, 01/08/25, 01/15/25, 01/22/25, 01/29/25, 02/05/25, and 02/12/25 the Wound Care Physician attempted manual debridement but had to stop due to pain and on 02/26/25 during wound care treatment Resident #59 was observed crying, grimacing, and had verbal reports to stop the dressing change. [...]

Inspectors wroteBased on observations, and staff and Consultant Pharmacist interviews, the facility failed to date and label insulin pens available for use in 4 of 6 medication carts (medication cart #5, #1, #2 and #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice prior to discharge from Medicare Part A skilled services for 2 of 3 residents (Resident #113 and Resident #302) reviewed for beneficiary notification.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to update a resident's care plan after a resident had an indwelling urinary catheter placed for 1 of 3 residents (Resident #26) reviewed for urinary catheters.

Inspectors wroteBased on observations, record review, resident, and staff interviews, the facility failed to secure a urinary catheter tubing to prevent tension and/or trauma for 1 of 3 residents (Resident #26) reviewed for urinary catheters.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to follow their infection control policies and procedures when Nurse Aide (NA) #1 failed to wear the required personal protective equipment (PPE) while toileting a resident (Resident #140) who was on enhanced barrier precautions (EPB) due to a wound and when after cleaning a wound for a resident (Resident #48) Wound Care Nurse #2 failed to doff her gloves, sanitize her hands and don clean gloves prior to applying skin prep around the wound in preparation for the wound dressing on a resident on EBP. This deficiency occurred for 2 of 3 staff members reviewed for infection control practices. 1. Review of the Enhanced Barrier Precautions (EBP) policy and procedure which is part of the Infection Control policies and procedures last updated 03/21/2024 revealed the following: Purpose: [...]

Inspectors wroteBased on record review, resident, Physician and staff interviews, the facility failed to schedule an ophthalmology consult appointment as ordered by the Physician for 1 of 1 resident reviewed for vision (Resident #67).

Inspectors wroteBased on observations, staff interviews and record review, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection or injury for 1 of 3 residents (Resident #107) reviewed with indwelling urinary catheters.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect the use of an antibiotic and the frequency of use for an anticoagulant, antidepressant, and diuretic for 1 of 6 residents (Resident #53) reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interviews and observations, the facility's Quality Assurance and Performance committee (QAPI) failed to maintain implemented procedures and monitor the interventions the committee put into place during the recertification and complaint investigation survey dated 05/16/22 and the recertification and complaint investigation survey dated 09/14/23. F 641 was originally cited during the recertification and complaint investigation survey dated 05/16/22. F 641 was re-cited during the recertification and complaint investigation survey dated 09/14/23. The continued failure of the facility during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance and Performance Improvement Program.