Keller Oaks Healthcare Center

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of four residents (Resident #1) reviewed for catheter and incontinence care. The facility failed to ensure staff provided Resident #1 timely perineal care after an incontinent episode when they failed to check and change the resident from 06:00 a.m. to 9:35 a.m. on 06/18/26. This failure could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 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 2 of 4 Residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure CNA B performed hand hygiene during incontinent care on Resident #1 on 06/18/26. 2. The facility failed to ensure CNA B utilized Enhanced Barrier Precautions and performed hand hygiene during incontinent care Resident #2 on 06/18/26. These failures could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident#1) of 4 residents reviewed for ADLs. The facility failed to ensure Resident#1 had her fingernail cleaned and trimmed on 05/19/26. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's quarter MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of: Muscle Weakness (Generalized) and Need For Assistance With Personal Care. The review further reflected the resident was dependent with ADL's (activity of daily living). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to 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 3 of 3 Residents (Resident #1, Resident #2, Resident #3) observed for infection control. 1. The facility failed to ensure PTA B, CNA C and RN A utilized enhanced barrier precautions during incontinent care and gait belt transfer on Resident #1 on 03/31/26. 2. The facility failed to ensure CNA C performed hand hygiene during incontinent care on Resident #2 on 03/31/26. 3. [...]

Inspectors wroteBased on observations , interviews, and record review, the facility failed to ensure that residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for one of nine residents (Resident #277) reviewed for incontinence and indwelling urinary catheter care in that: The facility did not obtain physician orders for indwelling catheter care and peri care for Resident #277 for March and April 2025. This deficient practice could place residents with indwelling catheters at risk of developing or worsening urinary infection and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for safety in the facility's only kitchen. 1. The facility failed to label and date three 1- gallon pitchers of liquid. 2. The facility failed to remove three dented cans from the dry food storage area. 3. The facility DA failed to wear a beard net while in the kitchen. The failures could place all residents at risk for food-borne illness.

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 2 of 2 Residents (Resident #16 and Resident #84) observed for infection control. The ABOM failed to perform hand hygiene while assisting Resident #16 and Resident #84 during the lunch meal on 05/06/2025. These failures could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one of four hallways (A hallway) medications carts in hallways that were reviewed for security and storage of drugs and biologicals. The facility did not ensure A hallway medication cart was locked and medications were not left on top of the medication cart unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 1 resident (Resident #1) of 6 residents reviewed for clinical records. -The facility failed to completely and accurately document Resident #1's weekly skin assessments and any follow-up assessments relating to new bruises documented on the shower sheets, which would indicate details of the bruises and care as necessary. This failure could place all residents at risk of having skin conditions that are untreated and having incomplete and inaccurate records, which could lead to harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Residents #1) of 7 residents reviewed for dignity. The facility failed to ensure Residents #1's rights to a dignified existence when there were flies on him, his g-tube was exposed, and his room had a strong foul odor. This failure could affect the residents by placing them at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 4 of 7 (Residents #1, #2, #3, and #4) reviewed for accommodation of needs in that: The facility failed to ensure Resident #1, #2, #3, and #4's call lights were within reach of the Resident. This failure could affect all residents who needed assistance and could result in their needs not being met.

Inspectors wroteBased on observation, interview 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 food items in the facility's only dry storage were dated and sealed appropriately. 2. The facility failed to ensure food items in the facility's only walk in refrigerator were dated and sealed appropriately. 3. The facility failed to ensure cleaning chemicals were not near prepared food. 4. The facility failed to ensure drinks and food for personal use were properly stored. 5. The facility failed to ensure the kitchen door opening to the outside was closed. These failures could place residents at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to residents with reasonable accommodation of resident needs and preferences by not providing a call light system within reach for 2 of 31 (Residents # 1 & #2) observed for call lights. The facility failed to ensure Residents #1 and #2 had a call light within reach to communicate to staff they needed assistance. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 2 of 25 opportunities resulting in an 8 percent medication error rate for 2 of 6 residents reviewed for medication administration. Facility failed to ensure Resident #80's and Resident #223's medications were administered as physician ordered as whole pills. Facility failed to ensure Resident #80's and Resident #223's medications were not crushed and mixed into a cocktail without a physician order. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for one (Resident # 223) of six residents reviewed for medication administration. Facility failed to verify Resident #223's Nifedipine Extended Release 12-hour blood pressure medication could be crushed without a pharmacist review or a physician order. This failure could place residents at risk for significant medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living (ADLs) independently received the necessary service to maintain good grooming and personal hygiene for 1 (Resident #1) of 3 residents. Facility failed to ensure Resident #1 was provided a shower as scheduled since her admission into the facility in December 2023. These failures could place the resident at risk of not receiving personal care services, experiencing decreased quality of life, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure five (Residents #1, #2, #3, #4, and #5) of thirteen residents received reasonable accommodation of needs. The facility staff did not place call lights within reach for Residents #1, #2, #3, #4, and #5. This failure could affect who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for four residents (Residents #75, #94, #95, #83) of 32 residents reviewed for ADL care. The facility failed to ensure Residents #75, #94, #95 and #83 were provided showers as scheduled. These failures could place residents at risk of not receiving personal care services and of having a decreased quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure that residents were free of any significant medication errors for 1 (Resident #94) of 6 residents reviewed for medications. The facility failed to ensure Resident #94 received his Semaglutide (1 mg/dose) pen-injector 4 mg/3 ml as ordered by the physician on 01/24/23. This failure could place residents whose medications were supervised by the facility at risk of experiencing serious side effects from possible interruptions to their medication regimen.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three (HA C) Hospitality Aides had successfully completed a State-approved training course for feeding assistance before feeding residents who required staff to feed them. The facility did not ensure HA C completed a state approved training course for feeding residents before assisting residents with feeding. This failure could affect residents who required assistance with eating by placing them at risk of aspiration and choking.