Northern Oaks Living & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 7 residents (Resident #1) reviewed for accuracy of MDS assessments. The facility failed to complete Resident #1's Hearing, Speech, Vision (Section B), Cognitive Patterns (Section C), Mood (Section D) and Health Conditions - Pain Assessment (Section J) on his Quarterly MDS assessment dated [DATE]. These failures could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could prevent residents from receiving correct care and services.

Inspectors wroteBased on interviews and record review, the facility failed to immediately inform the residents' representative about a significant change in the resident's physical status for 1 of 5 (Resident #1) of 5 residents reviewed for representative notification. The facility failed to notify Resident #1's Representative of a significant change on [DATE]. This failure could place residents at risk of not having their change of condition communicated to their physician, delay of treatment, and a decline in the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 3 (Resident #55, Resident #78, and Resident #87) of 20 residents reviewed for unnecessary medications. The facility failed to ensure Resident #55's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #78's PRN Lorazepam discontinued after 14 days or a documented rational for the continued provision of the medication. The facility failed to ensure Resident #87's PRN Lorazepam was discontinued after 14 days or a documented rational for the continued provision of the medication. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to dispose of mediations that were expired in accordance with professional standards for 1 of 3 medication carts (medication cart for Hall 200/300) reviewed for pharmacy services. The facility failed to ensure Resident #15's Nitroglycerin (medication used to treat chest pain) was not expired and was on the medication cart for Hall 200/300. The facility failed to ensure Resident #33's Ondansetron (medication used to treat nausea) was not expired and was on the medication cart for Hall 200/300. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 3 medication carts (medication cart for Hall 200/300) reviewed for pharmacy services. The facility failed to ensure Resident #2's Novolin 70/30 Flex pen (insulin- medication used to treat diabetes) was labeled with an open date on the medication cart for Hall 200/300. The facility failed to ensure Resident #69's Lantus Flex pen (insulin- medication used to treat diabetes) was labeled with an open date on the medication cart for Hall 200/300. These failures could affect residents prescribed medications in the facility and place them at risk for not receiving the correct medications, medication misuse, or receiving expired medications. Findings Included: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents or the resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option they preferred for 1 of 20 (Resident #37) residents reviewed for antipsychotic consents. The facility failed to ensure Resident #37 or her representative signed a consent for antianxiety medication lorazepam prior to administering the medication to Resident #37. This failure could affect residents who received psychoactive drugs by placing them at risk of not being informed of their medications risks and benefits to make informed decisions regarding their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #76) reviewed for incontinent care. The facility failed to ensure CNA-C and CNA-D provided proper incontinent care to Resident #76 by not cleaning his penis or genital area when performing a brief change. This failure could place residents at-risk for infection and skin breakdown due to improper care practices. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 20 (Resident #37) residents reviewed for hospice services. The facility failed to make sure that information on hospice care, that included the Texas Medicaid Hospice Recipient Election/Cancellation form, was included in Resident #37's current clinical record. The facility failed to make sure that information on hospice care, that included the Physician Certification of Terminal Illness form, was included in Resident #37's current clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent surveys and investigations of the facility including any plans of correction, without identifying information about complainants or residents, for 1 of 1 facility reviewed for resident rights. The facility failed to ensure the investigations that occurred on 1/26/2025, 3/07/2025, 5/25/2025, 8/01/2025, 10/16/2025, 11/07/2025, and 1/15/2026 with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to periodically review and revise for 1 (Resident #2) of 5 residents reviewed for care plans - The facility failed to update the care plan to remove the intervention floor mat from bedside to prevent falls for Resident #2. This deficient practice could place residents in the facility at risk of not receiving care appropriate for their needs and could lead to injury. Review of Resident #2's electronic face sheet dated 11/06/2025 reflected a [AGE] year-old female with an admission date of 01/09/2024 and most recent admission date of 02/12/2025. Resident #2's diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #1, Resident #2, and Resident #3) of 12 residents observed for assistance with ADL's. Resident #1, Resident #2, and Resident #3 had body odor and poor hygiene due to the facility failing to provide showers This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care, skin breakdown, feelings of poor self-esteem, and lack of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive and person-centered care plan, including measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 18 (Resident #60) residents reviewed for comprehensive care plans. The facility failed to implement care plan for Resident #60 to receive house shake with meals. These failures could place residents at risk of not having preferences and weight goals being met.

Inspectors wroteBased on interview, and record review, the facility failed to accurately assess each resident's status for 1 of 18 (Resident #19) residents reviewed for assessment accuracy. The facility failed to code Resident #19's Quarterly MDS assessment records accurately. MDS assessment coded that resident had received anticoagulation (medications that stop blood from clotting too easily) medication when resident did not receive that type of medication. This failure could place residents at risk of not receiving the proper care and services due to inaccurate assessment records.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the comprehensive care plan was reviewed and revised by a team of qualified persons after each assessment for 2 of 18 (Resident #50, and Resident #281) residents reviewed for comprehensive person-centered care plans. 1. The facility failed to revise Resident #50's comprehensive care plan to remove use of medication no longer ordered within 7 days of the completion of the comprehensive assessment. 2. The facility failed to include hospice services within 7 days of the completion of Resident #281's comprehensive assessment. Thes failures could affect the residents by placing them at risk for not receiving current care and services to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that residents had the right to a safe, clean, comfortable, and homelike environment for 6 (Resident #2, Resident #3, Resident #4, For Resident #5, For Resident #6, and Resident #7) of 8 residents reviewed for a clean and comfortable environment. 1. The facility failed to ensure a broken windowsill in Resident #2's bedroom was repaired, and the exposed wood was repainted. 2. The facility failed to ensure Resident #3 had access to cold water when the bathroom faucet was not repaired and missing cove base trim in the bathroom was not repaired or replaced that exposed damaged dry wall and wood. 3. The facility failed to repair the cove base trim in Resident #4's bedroom that exposed damaged dry wall and wood and failed to repair the bathroom sink that had dislodged from the wall. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 4 halls (hall 200 and hall 300) reviewed for environmental conditions by failing to ensure: 1. The door and the door casing of the entrance door of the community shower room was damaged. 2. The public bathroom on Hall 300 had damage to the tile on the wall and the wall to the right of the entrance was splattered with dark spots. 3. The wall in the community shower across from the toilet was dirty and the cove base trim was pulled back exposing damage to the drywall and wood. 4. The door and the door casing of the exit door on Hall 200 that led to the smoke area was damaged. 5. A light fixture in the hallway of Hall 300 next to the emergency exit contained numerous dead bugs and was brown in color. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. Facility failed to include a resident group in the decision to change the timing/hours between the supper and breakfast meal; the current schedule is for 15 hours between the meal times. This failure placed residents at risk of their nutritional needs, preferences, and requests being met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to store foods in the refrigerators and freezers properly. These findings placed residents at risk of food borne illnesses.

Inspectors wroteBased on interview, observation, and record review the facility failed to revise the resident's care plan for 3 (Resident #37, #33 and #129) of 24 residents reviewed for comprehensive care plans. 1. The interdisciplinary team failed to review and revise the plan of care for Residents #37, #33 and #129. These failures could affect residents by placing them at risk for not having their individual needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice, and failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents (Resident #9, Resident #17 Resident #27) reviewed for skin integrity. The facility failed to follow physician's orders which led to missed treatments for Resident # 9, Resident #17 and Resident #27's pressure ulcers. These failures could place residents at risk of wound deterioration, wound development, and infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who entered the facility without an indwelling catheter was not catheterized unless the resident's clinical condition demonstrated that catheterization was necessary or a resident who entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 2 of 4 (Resident #18, 33) reviewed for catheters. The facility failed to obtain orders for care and monitoring of Resident #18's catheter from 5/23/23 to 8/17/23. The facility failed to obtain orders for care, monitoring or careplan needs for Resident #33's catheter from 8/20/23 to 8/28/23. These findings placed residents at risk of complications related to urinary continence and catheters.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days and to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 (Resident #35, Resident 45, and Resident #70) of 6 residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #35's PRN Clonazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 2. The facility failed to ensure Resident #41's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or a documented rational for the continued provision of the medication. 3. [...]

Inspectors wroteBased observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts and 1 of 1 treatment carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended by MA-A. The facility failed to ensure treatment cart was locked when unattended by MA-B. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions.

Inspectors wroteBased on interview and record review the facility failed to obtain services furnished by outside resources in a timely manner 2 of 6 residents (Resident #70 and Resident #58) reviewed for outside resources. 1. The facility failed to ensure Resident #70's physician's order to refer GI (Gastro-Intestinal) was done and an appointment arranged in a timely manner. 2. The facility failed to ensure Resident #58's physician's order to refer GI (Gastro-Intestinal) was done and an appointment arranged in a timely manner. This failure could place residents at risk of not receiving treatments on a timely basis due to delays in having treatment arrangements made.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for 2 of 2 (Resident #39 and Resident #79) reviewed for DNR status. The facility failed to ensure Resident #39's electronic records were correctly updated and complete with a Full Code status. The facility failed to ensure Resident #79's DNR status were correctly placed in the resident's closed record electronic charting. This failure could place residents at risk for inaccurate or incomplete clinical records regarding effective Full Code and/or DNR status.

Inspectors wroteBased on observations, interviews and record reviews, 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 5 (NA D, MA A, and PT E) staff reviewed for infection control. The facility failed to ensure staff (NA D and PT E) wore face coverings correctly according to manufactures specifications while providing direct care services. The facility failed to ensure MA-A sanitized the blood pressure cuff before or after use on a Resident #31, Resident #62, and Resident # 66. This deficient practice could affect residents that reside in the facility and placed them at risk of infection.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident right to formulate an advance directive for 1 of 5 residents (Resident #27) reviewed for advance directives. The facility failed to ensure that Resident #27's advanced directive consent, Out of Hospital Do Not Resuscitate (OOH-DNR) order, was signed by two witnesses. This failure could place residents at risk of receiving treatments that go against their personal preferences and does not allow them to make an informed decision about their care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care for 1 of 4 (Resident #129) residents reviewed for baseline care plans. The facility failed to address the PICC line care needs in Resident #129's baseline care plan. These failures placed residents at risk for adverse events that are most likely to occur right after admission.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The total number and the actual hours worked by the Registered nurses, Licensed practical nurses or licensed vocational nurses or Certified nurse aides directly responsible for resident care per shift for 2 of 2 days reviewed. The facility failed to ensure the daily staffing information was posted in a prominent location on 08/27/2023 and 08/28/2023. This failure could place residents, their families, and visitors at risk of not having the staffing information readily accessible for review, residents and visitors are not able to know how many staff are currently working to provide care on all shifts. Findings Included: [...]