Oak Knoll Health and Rehabilitation, LLC

Inspectors wroteBased on record review, interview, review of an Online Incident Report and review of facility policy Abuse, Neglect Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure Resident Identifier RI #1 was not talked to in a demeaning way by a Certified Nursing Assistant (CNA) #4. This incident occurred on 1/28/24 and affected RI #1. This was cited as a result of investigation of complaint/report number AL00046804 and affected RI #1, one of one resident verbally abused.

Inspectors wroteBased on observations, interviews, and a review of a facility policy, Supervised Smokers, the facility failed to ensure Resident Identifier (RI) #1 was not found with a lighter in his possession on two separate occasions. This affected RI #1, one of 13 residents listed as a smoker. This was cited as a result of investigation of complaint/report number AL00047459. Findings Include: Review of a facility policy Supervised Smokers with an effective date of 10/15/2022 documented . PROCESS: . 2. Smoking materials should be kept at the nurse's station, and . 3. No fire igniting materials (matches/lighters) should be kept in resident/guest(s) possession. Smokers should obtain lighting materials from staff. On 5/1/24 at 3:50 PM during an interview with Registered Nurse (RN) #3, she said she recalled RI #1 and CNA #4 arguing over a lighter. RN #3 said she never saw the lighter. [...]

Inspectors wroteBased on observations, record review, interviews and review of facility policy, the facility failed to store, prepare, and distribute food in a sanitary manner for two (2) of three (3) days of the survey. This deficient practice has the ability to affect all residents that received food or beverage from the facility's kitchen.

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility failed to follow the menus. Specifically, the facility failed to follow the recipes for the pureed menu items, failed to follow the menu for pureed corn bread, and failed to adhere to the appropriate serving size of the bread for 12 of 12 residents that received pureed diets (Resident #5, Resident #6, Resident #22, Resident #23, Resident #25, Resident #27, Resident #30, Resident #31, Resident #36, Resident #78, Resident #139, and Resident #140).

Inspectors wroteBased on observation, record review and interviews the facility failed to develop and implement a comprehensive care plan for one (1) of two (2) residents that received dialysis services (Resident #66). The facility failed to implement the care plan regarding obtaining information from the dialysis center and failed to assess the fluid intake for Resident #66 who was on a fluid restriction.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure ongoing communication between the facility and the dialysis center for two (2) of two (2) sampled residents (Resident #66 and Resident #86) reviewed for dialysis. In addition, the facility failed to complete intake and output records per Physician's Orders for Resident #66 who had a fluid restriction in place and failed to follow-up on the dialysis center Dietician's recommendation for Novosource (nutritional supplement).

Inspectors wroteBased upon observation, interview, and policy review the facility failed to ensure that medications were stored properly in one of two medication carts surveyed. One blister pack card of expired medication was found in Medication Cart #2.

Inspectors wroteBased on observations, interviews, and review of facility policy, two (2) staff failed to wear all required personal protective equipment (PPE) when entering two (2) residents' isolation rooms during meal-service (Resident #139 and Resident #140).

Inspectors wroteBased on observation, interview and review of the Potter / [NAME] Fundamentals of Nursing Ninth Edition, the facility failed to ensure licensed staff did not leave medications unattended at Resident Identifier (RI) #17's bedside while she left the resident's room for needed supplies. This affected one of six residents observed for medication pass and one of four nurses observed for medication pass. Findings Include: A review of the Potter/[NAME] Fundamentals of Nursing Ninth Edition Chapter 32 Unit V Foundations for Nursing Practice Administering Oral Medications . Implementation . page 657 revealed: . l. Do not leave medications unattended. Nurse is responsible for safekeeping of drugs. RI #17 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Diabetes Mellitus, Hypertension, Kidney Transplant Status, Pain and Chronic Pulmonary Edema. [...]

Inspectors wroteBased on interviews, record review, a review of a facility's policy titled, Incidents and Accidents, and a review of a facility document titled, Resident Incident Report, the facility failed to ensure Resident Identifier (RI) #38's bed was locked during peri-care on 08/23/17. RI #38 fell out of the bed which resulted in RI #38 being transported out of the facility for emergency treatment for a contusion to the left forehead. This affected one of two sampled residents reviewed for falls. Findings Include: A review of the facility's policy titled, Incident and Accidents, with an effective date of August 26, 2013, revealed: PURPOSE: The resident environment remains as free of accident hazards as is possible . RI #38 was admitted to the facility on [DATE] with diagnoses of Cerebrovascular Disease, and Vascular Dementia without Behavioral Disturbance. [...]

Inspectors wroteBased on medical record review, interviews, a review of the facility's policy titled, Bowel and Bladder Program,and a review of Resident Identifier's (RI) #99's Care Plan, the facility failed to ensure RI #99 was toileted upon request to maintain bladder function. This affected one of seven residents reviewed for bowel and bladder function. Findings Include: A review of the Facility's policy titled,Bowel and Bladder Program, with an effective date of October 1, 2010 revealed: . PURPOSE: A resident who is incontinent of bowel and bladder receives appropriate treatment & (and) services to prevent urinary tract infections & to restore as much normal bowel/bladder function as possible. STANDARD: Each resident who is incontinent of urine/bowel is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary/bowel function as possible . [...]

Inspectors wroteBased on observations, interviews, medical record review, a review of a facility's policy titled, Dentures-Cleaning and Storing, and [NAME] AND PERRY'S, FUNDAMENTALS OF NURSING, the facility failed to ensure RI (Resident Indentifer) #30's dentures were not soaking in a dirty, discolored solution containing debris and sediment. This was observed on two of three days of the survey. This deficient practice affected RI #30 one of twenty five sample residents. Findings Include: A review of a facility's policy titled, Dentures-Cleaning and Storing, with an effective date of October 1, 2010 revealed: .PURPOSE: Clean dentures help to freshen and clean the resident's mouth and lessen the potential for infections of the mouth. A review of [NAME] AND PERRY'S, FUNDAMENTAL OF NURSING, NINTH EDITION, CHAPTER 40, page 841 revealed: . Denture Care. [...]