Oak Creek Terrace Inc

Inspectors wroteBased on record review, interview, and policy review, the facility failed to implement a baseline care plan within 48 hours and have fall interventions in place. This affected one (#58) of three residents reviewed for falls. The facility census was 64.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure fall prevention interventions were being followed. This affected one (#60) of three residents reviewed for falls. The facility census was 64.

Inspectors wroteBased on observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidance, and policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing care for a resident who was positive for COVID-19, and failed to complete proper hand hygiene prior to exiting the room. This affected one (#24) of five residents reviewed for infection control. The facility identified there were five residents who were positive for COVID-19 (and resided on the dementia care unit) during the survey. This had the potential to affect 10 residents who resided on the dementia care unit who were not positive for COVID-19.

Inspectors wroteBased on observation, medical record review, and staff interviews, the facility failed to ensure infection control practices were followed during a dressing change for a pressure ulcer. This affected one (#29) of the two residents reviewed for pressure ulcers during the annual survey. The facility identified two residents (#27 and #29) with pressure ulcers. The facility also failed to ensure their Water Management Plan (WMP) was followed. This had the potential to affect 62 residents who resided in the facility. The facility census was 62.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure food and utensils were stored in a safe and sanitary manner. This had the potential to affect 61 out of the 62 residents as the facility identified one resident (#41) with a diet of nothing by mouth (NPO) and received no food from the kitchen. The facility census was 62.

Inspectors wroteBased on observation, medical record review, and staff interviews, the facility failed to ensure physician orders were followed during a dressing change of a pressure ulcer. This affected one (#29) of the two residents reviewed for pressure ulcers during the annual survey. The facility identified two residents (#27 and #29) with pressure ulcers. The facility census was 62.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure a fall with major injury was thoroughly investigated. This affected one (#29) resident of the five residents reviewed for accidents. The facility census was 62.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure the placement of a gastronomy tube (G-tube), failed to ensure a resident was positioned at 30 - 45 degree angle, failed to ensure the syringe for administering medications via the G-tube was dated, and failed to ensure medications being administered through the G-tube were properly diluted prior to administering them. This affected one (#41) of the two residents identified by the facility as having a G-tube. The facility census was 62.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents' medical records were complete and accurately documented when a resident sustained a fall with a major injury and was documented in a resident's medical record. This affected one (#29) of the five residents reviewed for accidents during the annual survey. The facility census was 62.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure comprehensive care plans were completed in the areas of activities, activities of daily living, dehydration, and pain . This affected six (#23, #05, #43, #467, #469, and #57) of 18 residents reviewed for comprehensive care plans. The facility census was 62.

Inspectors wroteBased on observation and interview, the facility failed to use a recipe to accurately make pureed texture food. This affected all six Residents (#07, #18, #23, #29, #42, #469) with orders for pureed diets. The facility census was 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dignified care in relation to a privacy bag for one Resident (#467)'s catheter of one reviewed for dignity. Facility census was 62.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure care conferences were conducted as required. This affected three (Resident #05, #49, and #61) out of three residents reviewed for care conferences. The facility census was 62.

Inspectors wroteBased on observation, medical record review, and staff and resident interview the facility failed to ensure communication devices were implemented for one (#49) of one resident reviewed for communication during the annual survey. The facility identified there was only one resident who spoke a foreign language. The facility census was 62.

Inspectors wroteBased on observation, staff and family interviews, and medical record review, the facility failed to ensure activities were provided for two (#49 and #23) of three dependent residents reviewed for activities. The facility census was 62.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide adequate fluids to one Resident (#469) reviewed for hydration. The facility census was 62.

Inspectors wroteBased on record review and staff interview; the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected two (Resident #17 and #30) of 24 residents reviewed for accuracy of the MDS assessment. The facility census was 64.

Inspectors wroteBased on record review and staff interview; the facility failed to develop and implement a person-centered comprehensive care plan for antipsychotic medication use. This affected one (Resident #17) of sixteen resident reviewed for the development of person-centered comprehensive care plans. The census was 64.

Inspectors wroteBased on observation, record review and staff interview; the facility failed to review and revise a comprehensive care plan to include a change in a residents dialysis access site. This affected one (Resident #7) of 16 residents reviewed for care plans. The facility census was 64.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to provide adequate care and treatment with the application of a physician ordered compression stockings. This affected one (Resident #216) of sixteen residents reviewed for quality of care. The facility census was 64.

Inspectors wroteBased on observation, record review, and staff interview; the facility failed to ensure fall interventions were in place as ordered by the physician. This affected one (Resident #17) of three resident reviewed for falls. The facility census was 64.