Oak Creek Rehabilitation Center of Kimberly

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 33 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, undignified, or b) residents were injured due to unsafe areas in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when staff did not offer or encourage residents hand hygiene prior to meals, replace resident's soiled equipment, and implement water management control and monitoring measures. This was true for the facility and 1 of 3 residents (Resident #7). These failures placed residents at risk for cross-contamination and infection.

Inspectors wroteBased on record review, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse. This was true for 1 of 3 residents (Resident #4) reviewed for abuse. This failure placed all residents at risk of ongoing abuse, potential physical, and psychosocial harm.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to ensure a copy of the residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This was true for 1 of 1 Residents (Resident #2) reviewed for Ombudsman notification. This failed practice had the potential to affect all residents by; 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on the State Operations Manual - Appendix PP, facility policy, record review, and staff interview, it was determined the facility failed to make a referral to the state mental health authority for a possible new PASRR level II evaluation when residents were diagnosed with a new serious mental disorder. This was true for 1 of 1 resident (Resident #6), whose PASRR records were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed, treated, and monitored appropriately.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to follow physician orders of delivering specific medications when residents did not have BM within 72 hours for 2 of 8 residents (#5 and #21) whose records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident received oxygen as prescribed by the provider. This was true for 1 of 3 residents (Resident #7) reviewed for respiratory care. This failure created the potential for respiratory difficulties or impaired breathing.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP, staffing schedules, and staff interviews, it was determined the facility failed to a) ensure full-time nurse aides working less than 4 months are enrolled in a State approved nurse aide training and competency evaluation program (NATCEP) and b) ensure full-time nurse aides working in the facility more than 4 months have successfully completed a NATCEP. This was true for 10 of 13 nurse aides whose personnel files were reviewed. This failure had the potential to result in negative outcomes for the 33 residents living in the facility.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP, observation, and staff interview, it was determined the facility failed to ensure the daily nurse staffing information was accurately posted for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 2 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors when 1 of 2 residents (Resident #6) did not receive her Invega injection (antipsychotic medication) as ordered by the physician. This failure had the potential to cause harm if the resident's psychiatric behaviors increased due to not receiving her medications timely.

Inspectors wroteBased on observations, record review and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and biologicals were labeled when opened. This was true for the facility. This failure created the potential for residents to receive expired medications with decreased efficacy, use of expired biologicals, and the potential for theft and/or diversion.

Inspectors wroteBased on observation, interview, and review of the Idaho Food Code, the facility failed to ensure food was appropriately stored, distributed, and labeled. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination, use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean and comfortable environment for residents in 2 of 2 shower rooms (200 hall and 300 hall). This failure had the potential to put residents at risk for a diminished quality of life.

Inspectors wroteBased on policy review, record review, facility investigation review, and staff interview, the facility failed to prevent physical abuse, verbal abuse, and neglect for 1 of 3 residents (Resident #15) reviewed for abuse. This deficient practice placed Resident #15 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect him from physical and verbal abuse and neglect from LPN #1.

Inspectors wroteBased on policy review, record review, facility investigation review, and staff interview, it was determined the facility failed to report an allegation of physical and verbal abuse and neglect to the State Survey Agency. This was true for 1 of 3 residents (Resident #15) reviewed for abuse. This failure resulted in harm to Resident #15 when the allegation of physical and verbal abuse was not acted on in a timely manner, investigated, and measures implemented to protect residents during the investigation.