Green Oaks Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of 3 residents medication (Resident#4, Resident #200's and Resident#99) medications on 2 of 4 medication carts,(200 hall nurses cart and 200 hall medication aides cart ) reviewed for pharmacy services.1. The facility failed to ensure proper disposal of Resident#4's Tylenol 300/30mg (controlled medication) by taping the blister pack of a narcotic medication. 2. The facility failed to ensure proper disposal of Resident#4's Tylenol 300/30mg (controlled medication) medication that was discontinued. 3. The facility failed to ensure proper disposal of Resident #99's Lyrica capsule 300mg (controlled medication) when the blister pack was damaged.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure,label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for five residents( Resident#10, Resident #33, Resident#13's , Resident#122, and Resident#19's) on two medication carts (100 and ,200 hall nurses medication carts ) of four medication carts reviewed for medication storage. 1. The facility failed to ensure Resident #33's Naphcon A Eye drop was secured in the medcart.2. The facility failed to ensure Resident#10's: Fiasp FlexTouch 100 UNIT/ML Solution pen-injector (a rapid-acting mealtime insulin) was dated after opening and before it was stored in the medication cart.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a Comprehensive Assessment within 14 calendar days after admission, as well as at least once every 12 months, for one (Resident #124) of seven residents reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #124 was completed within 14 days after his admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for one of six residents (Resident #16) reviewed for assessments. Resident #16's PASRR Level I was negative for mental illness despite having a diagnosis of anxiety, depression, and schizoaffective disorder. This could place residents at risk of not receiving necessary specialized services to meet their individual needs. Record review of Resident #16's MDS assessment dated [DATE], reflected an [AGE] year-old female, originally admitted to the facility on [DATE], with a BIMS score of 12 which indicated moderate cognitive impairment and diagnoses that included: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #124) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #124 within 48 hours of his admission. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #16) reviewed for comprehensive care plans. The facility failed to ensure Resident #16's comprehensive care plan was accurate and reflected the resident's PASRR status. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, for 1 of 4 residents (Resident#99) reviewed for respiratory care. The facility failed to ensure that Resident #99's oxygen tubing's were bagged in a plastic bag, and which was consistent with professional standards when the nasal cannula was observed dragging on the floor. The facility failed to ensure that Resident #99 was receiving continuous oxygen per physician orders when she was observed without oxygen. These failures could place residents at increased risk of receiving inadequate oxygen support, infections that could result in a decline in health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one hydration carts observed for infection control. The facility failed to ensure proper infection control procedures were followed when Resident #49's family member utilized a metal ice scoop to obtain ice from the hydration cart, located in the residential hallway. Resident #49's family member then poured the ice into two personal cups, touching the metal scoop on the insides of each cup. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required it for 1 of 8 residents (Resident #1) reviewed for pain. The facility failed to make sure that each resident's clinical record contains the physician's signed and dated orders that also were handled appropriately if any changes were made for 1 (Resident #1) of 8 Residents reviewed for physician orders in that: - Facility failed to obtain physician orders for [[NAME]] Cold Therapy Unit which was used to provide cold therapy to reduce pain and swelling for Resident #1. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the resident's care and place residents at risk for harm due to inaccurate records

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for one (Resident #1) of two residents reviewed for perenteral fluids. 1. The facility failed to ensure the dressing on Resident #1's PICC line (used to deliver medications and other treatments directly to the large central veins near the heart) was changed timely. Resident #1 went without a dressing change for 19 days. 2. The facility failed to have orders for PICC line dressing changes and flushes. The failures could affect residents by placing them at risk for infections.

Inspectors wroteBased on interview and record review the facility failed to maintain privacy of medical records for 1 (Resident #2) of 5 residents reviewed for privacy of medical records. The facility (RN B) failed to ensure the privacy of Resident #2's personal information on 1/31/25. During Resident #1's discharge home, RN B included Resident #2's Methocarbamol Blister Pack (pain medication) which contained Resident #2's personal identifying information labeled (name and date of birth ) to Resident #1 and Resident#1's FM. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals.

Inspectors wroteBased on interviews and record review, the facility failed to complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter), for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility (RN B) failed to complete the Discharge Summary Nursing Section regarding a reconciliation of Resident #1's medications when she discharged home on 1/31/25. This failure placed residents at risk for a lack of continuity of care and adequate medication administration after they are discharged home.

Inspectors wroteBased on interviews and record review, 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 (Resident #1) of 5 residents reviewed for pharmacy services. The facility (LVN B) failed to follow the facility's policy for reconciling unused medications when Resident #1 discharged home on 1/31/25, which resulted in an inaccurate reconciliation of Resident #1's medications. LVN B sent Resident #2's Methocarbamol Blister Pack (pain medication) home with Resident #1 and Resident#1's FM. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the standby refrigerator temperature measured at 41F or less. 2. The facility failed to ensure walk-in refrigerator food items were dated and labeled. 3. The facility failed to ensure dry storage food items were dated, labeled, and stored securely. 4. The facility failed to ensure canned goods were free of dents. 5. The facility failed to ensure prepared foods items were covered and utilized separate utensils to ensure the food was free of cross-contamination.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 Residents (Resident #82) observed for infection control and 4 of 4 quarters reviewed for water management. 1. The facility staff failed to use proper technique when flushing Resident #82's IV while the resident was on enhanced barrier precautions. 2. The facility failed to implement a water management program per facility policy. These failures could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids administered were consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one (Resident #68) of six residents reviewed for periperal intravenous care. The facility failed to ensure Resident #68's peripheral intravenous (this is a catheter placed into the vein for short term fluids and or antibiotics use) dressing was dated with the insertion date. These failures could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for one of eight residents (Resident #67) reviewed for storage of medication and 1 of 6 medication storage carts (Nurses' Treatment Cart) observed for drug security. 1. Nurses' Treatment Cart was left unattended and unlocked outside the women's bathroom on 01/08/25. 2. The facility failed to ensure medications were not left at bedside for Resident #67. This deficient practice could affect residents at risk of lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 5 residents (Resident #1) reviewed for Care Plans. The facility failed to complete a comprehensive care plan for Resident #1. This failure could place residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 (dinner 05/07/2024) meals observed . 1. The facility failed to follow the menu. 2. The facility failed to ensure Anonymous #2 received milk, health shake and roll at dinner on 05/07/2024. 3. The facility failed to ensure meal tickets were updated to match the menu and what residents were served. These failures could place residents at risk for weight loss and a decrease in quality of life.

Inspectors wroteBased on, interview and record review, the facility failed to ensure that residents are free of any significant medication errors for 1 (Resident #1) of 11 residents reviewed for significant medication error. The facility staff failed to verify Resident #1's allergy to penicillin before administering antibiotic containing penicillin from 01/07/24 to 01/18/24. The facility staff failed to recognize or check to ensure the antibiotic Resident #1 was receiving did not have penicillin in it when some staff knew the resident was allergic to penicillin. Resident #1 expired on 01/19/24. An IJ was identified on 01/20/24. The IJ template was provided to the facility on [DATE] at 12:15 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 8 of 8 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) reviewed for Comprehensive Care Plan in that: The facility failed to ensure Resident #1, Resident#2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 and Resident #8 or the resident's representative were invited to participate in the residents' care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their cares.

Inspectors wroteBased on observation, interview and record review the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, which included to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken for 1 of 1 incidents reviewed for abuse and neglect. The facility failed to submit the investigation findings for 1 of 1 incident of injury of unknown origin within five business days of serious bodily injury, which included injury of unknown source. This failure could place residents at risk of abuse, neglect, and serious bodily injury.