Lady of the Oaks Retirement Manor

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 (#3, #86, #91, #104) of 4 (#3, #86, #91, and #104) residents reviewed for ADLs.

Inspectors wroteBased on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service as evidenced by:1. S8DA failing to cover exposed facial hair while serving food to residents,2. Food items in the facility's kitchen cooler and freezer were unlabeled, opened, and undated;3. lack of cleanliness of the facility's kitchen;4. Failing to ensure kitchen equipment was in good repair; and5. Failing to ensure foods on the food service line were at appropriate temperatures. This deficient practice had the potential to affect the 102 residents who consumed foods from the kitchen.

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 of communicable diseases and infection. This was evidenced by:A dirty trash can on Resident #115's bed. Staff failing to perform appropriate hand hygiene during medication administration; andStaff failing to follow enhanced barrier precautions (EBP) for Resident #33 and Resident #78.

Inspectors wroteBased on interviews and record review, the facility failed to file a grievance for a complaint of missing clothes for 1 (Resident #96) of 1 resident reviewed for grievances.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who had a qualifying diagnosed mental disorder were referred to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #29) out of 42 sampled residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement the plan of care per the physician's orders for 1 (#18) of 42 sampled residents, by failing to change Resident #18's left arm dressing, and elevate the resident's swollen left arm while she was in bed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure services provided met nursing professional standards for medication administration by failing to ensure medications were not left at the bedside for 2 (#40 and #61) out of 42 sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staffing information was complete, accurate, and posted daily. The facility's census was 105.

Inspectors wroteBased on records reviewed, observations, and interviews, the facility failed to ensure the resident's care plan and physician's orders were followed for 3 (#11, #91, and #102) of 34 sampled residents. This was evidenced when: 1. Facility staff failed to administer Resident #11, and Resident #102 their therapeutic diets as prescribed by the physician. 2. Facility failed to maintain right and left ear cushions to nasal cannula for Resident #91 3. Facility staff failed to ensure Resident #102 was assisted in meal set up per her comprehensive care plan, and failed to administer oxygen according to physician orders.

Inspectors wroteBased on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: 1. opened food items in the walk-in cooler not labeled with the date and time, name of food; and 2. expired food in the walk-in cooler and walk-in deep freezer. This facility had a census of 106 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received assistance with incontinent care for 2 (#61 and #72) of 8(#3, #31, #43, #57, #61, #72, #82, and #92) residents investigated for ADL care.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide a safe homelike environment for 1 (#100) out of 6 (#21, #24, #38, #61, #92, and #100) residents sampled for environment.

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' rights to be free from neglect by failing to provide incontinence care for a dependent resident for 1 (#3) resident out of 3 (#1, #2, #3) sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#77) out of 33 sampled residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and/or implement a person centered care plan by failing to: 1. Ensure staff repositioned Resident #47 every 2 hours. 2. Develop a plan of care for the use of hand rolls for Resident #72. 3. Ensure Resident #77's bed alarm was in proper working condition. This deficient practice had the potential to affect all the residents who reside in the nursing home.

Inspectors wroteBased on record review, observations and interview, the facility failed to ensure that a resident's enteral feeding was properly changed for 1 (#61) resident out of 1 (#61) sampled resident reviewed for tube feeding.

Inspectors wroteBased on record review and interviews the facility failed assure the nursing staff were competent to ensure 1 (#3) of 33 sampled residents that was allergic to morphine did not receive this medication. Record review of Resident #3's face sheet (document that gives a resident's information at a quick glance) revealed she was admit to the facility on [DATE]. She was on Hospice care with diagnosis of End Stage Parkinson's disease. Her face sheet further revealed she was allergic to the medication, Morphine. Record review of Resident #3's care plan read in part, I am at risk for complications r/t (related to) my allergy. I am allergic to MORPHINE. I have no complications at this time r/t my allergy. My clinical record will be labeled to alert everyone to my allergies. Record review of Resident #3's physician orders revealed she was admitted to Hospice on 02/06/2024. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day, on a weekend for 2 days on the dates of 10/21/2023 and 10/22/2023.

Inspectors wroteBased on record review and interview, the facility failed to coordinate care as evidenced by failing to obtain pertinent information from the hospice agency for 1 (#152) out of 2 (#3, #152) residents investigated for hospice.

Inspectors wroteBased on observation and interview, the facility failed to maintain cleanliness of medication carts for 1 (MC#1) of 4 (MC1, MC2, MC3, MC4) medication carts observed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the spread of Coronavirus Disease-2019 (COVID-19) as evidenced by staff not putting on the required Personal Protective Equipment (PPE) before entering isolation rooms. This deficient practice had the potential to affect a census of 100 residents.