Oak Knoll Skilled Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for two out of three residents sampled for falls. Staff failed to put leg rest on one resident's wheelchair, who put his/her feet down while staff propelled the chair, resulting in the resident falling from the wheelchair. The resident obtained a laceration on his/her forehead (Resident #76). In addition, staff failed to follow acceptable standards of practice when staff transferred the resident without using a gait belt (a transfer belt secured around the resident's waist, over clothing, used to steady and guide a resident who bears some weight) (Resident #53). The census was 69. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate an injury of unknown origin for one of three sampled residents (Resident #1). The census 67. Review of the facility's policy on Injuries of Unknown Origin, updated 4/30/20, showed the following: -Investigation should include Who, What, When, Why and How. Enable the investigator to record the information and establish a reasonable cause known source of the incident or injury within 24 hours of the incident or injury. If the investigator is unable to establish a reasonable cause or known source, further investigation is required. -Extended Investigation: Further investigation is required if there is Injury of Unknown Origin or Suspected Abuse within 24 hours and 1 hour for Abuse. The following will be needed: Statements from all involved witnesses and reporters. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident was free from physical abuse from a staff member (Resident #1). The sample was six. The census was 68. The Administrator was notified on 5/27/25 at 1:22 P.M., of the past non-compliance, which occurred on 5/18/25. The facility provided in-servicing for all staff regarding the facility's abuse and neglect policy with emphasis on reporting in a timely manner. The deficiency was corrected on 5/20/25. Review of the facility's Abuse and Neglect Policy, dated 5/14/24, showed the following: -Purpose: The facility has a ZERO TOLERANCE policy on any form of abuse or neglect against residents. Each resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, and neglect. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents was free from abuse. Certified Nurse Aide (CNA) A pulled on Resident #1's hair while taking the resident back to his/her room for hygiene care. The census was 62. The Administrator was notified on 4/3/25, of the past non-compliance. On 3/26/25, the management was notified of an abuse allegation that occurred the evening of 3/25/25. Upon notification of an abuse allegation on 3/26/25, the facility immediately suspended staff, investigated and implemented abuse/neglect in-servicing to all facility staff. During the onsite investigation, interviewed staff verified recent in-servicing and verbalized education. The deficiency was corrected on 3/26/25. Review of the abuse/neglect policy, revised 5/24/23, showed: -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure complete, accurate and individualized care plans to address the specific needs of residents for five of 18 sampled residents (Resident #2, #36, #34,#26 and #13). The census was 66. Review of the facility Care Plan Policy, dated 2001, revised [DATE], showed: -An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure bed rails were accurately assessed as a necessary device prior to installation and use for five of 18 sampled residents (Resident #62, #36, #26, #2 and #13). The facility also failed to document usage in the resident's care plan. The census was 66. Review of the facility's Proper Use of Side Rails policy, revised October 2010, showed: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids to and prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -General Guidelines; -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week. The facility maintained a census of greater than 60 residents, and this deficiency had the potential to affect all residents. The census was 66. Review of the facility's daily assignment sheets, dated 4/20/24 through 5/20/24, showed no RN was scheduled on 4/22, 4/24, 4/26, 4/29, 5/1, 5/3, 5/6, 5/8, 5/9, 5/15, 5/17, and 5/20. During an interview on 5/21/24 at 9:04 A.M., RN B said he/she worked part-time, every Tuesday, Thursday and some weekends. During an interview on 5/22/24 at 11:45 A.M., the Director of Nursing (DON) said there were three RNs in the facility, including herself. She said RN B worked Tuesdays, Thursdays and every other weekend. The other RN worked every other weekend only. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records for all controlled drugs with sufficient detail to enable an accurate reconciliation for one of one controlled substance binders reviewed. This had the potential to affect all residents with controlled substance orders. The census was 66. Review of the facility's Controlled Substance Policy, dated December 2011, showed: -Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II (drugs with a high abuse risk) and other controlled substances (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction); -The Director of Nursing (DON) services will identify staff members who are authorized to handle controlled drugs; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored in accordance with acceptable professional principles when staff walked away from the medication cart, leaving it unlocked. In addition, staff left the medication room unlocked. The census was 66. Review of the facility's Storage of Medications Policy, dated April 2007, showed: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain food under sanitary conditions by not ensuring food was labeled and dated after opened. This had the potential to affect all residents who consumed food from the facility kitchen. The census was 66. Review of the Dietary Infection Control/Sanitation Policy, undated, showed: -Food is stored in a safe and sanitary manner; -Food stored in freezers and refrigerators are covered, labeled and dated, especially foods taken out of their original containers and leftovers. Observation of the kitchen on 5/20/24 at 12:12 P.M., 5/23/24 at 1:41 P.M., and on 5/24/24 at 9:00 A.M., showed: -A plastic bag of frozen hamburger, opened and undated; -A plastic bag of frozen pork chops, opened and undated; -A plastic bag of frozen hash browns, opened and undated; -A plastic bag of frozen taco meat, opened and undated; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that in accordance with acceptable professional standards and practices, medical records were complete and accurately documented including the administration of medications and treatments for six residents (Resident #13, #30, #26, #2, #51 and #24). The sample was 18. The census was 66. Review of the facility's Administering Medication Policy, dated April 2010, showed: -Policy statement: medications shall be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; -The Director of Nursing (DON) Services will supervise and direct all nursing personnel who administer medications and/or have related functions; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program when staff failed to wear appropriate personal protective equipment (PPE), in accordance with the facility's policy, during high-contact activities with residents on enhanced barrier precautions (EBP, precautions for use during high-contact resident care activities for residents infected with a multidrug-resistant organism (MDRO, microorganisms that are resistant to one or more classes of antimicrobial agents) or any resident who has a chronic wound and/or indwelling medical device) for three residents (Residents #30, #46 and #24). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff completed routine inspections of bed/side rails as part of a regular maintenance program to identify areas of possible entrapment for five of 18 sampled residents (Resident #62, #36, #26, #2 and #13). The census was 66. Review of the facility's Proper Use of Side Rails policy, revised October 2010, showed: -The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids to and prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms; -General Guidelines: -Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents; -An assessment will be made to determine the resident's symptoms or reason for using side rails. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' needs were met by failing to ensure 10 residents who needed assistance with meal setup and eating were served and assisted for meals at the same time as the other residents in the dining room that did not require assistance. The ten residents sat and watched others at their table eat while they waited for food. Three of the ten residents were sampled residents (Resident #4, #2, and #3). Resident #4 was the last to be provided a meal and assistance with eating and waited over 30 minutes. The sample size was 4. The census was 70. 1. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/22/23, showed: -Severe cognitive impairment; -Eating: Setup or clean-up assistance. Helper sets up or cleans up. [...]

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed and submitted for processing for four of 17 residents (Resident (R)13, R35, R36 and R137) in the sample. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident (R) 28) received quarterly personal fund statements. Specifically, R28 was cognitively impaired and R28's Resident Representative (RR) did not receive quarterly personal fund statements for January through September 2022.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the power of attorney (POA) or Hospice when a resident had a fall and was transferred to the hospital for one of one resident (Resident (R) 21) reviewed in a total sample of 17 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three residents (Resident (R)32, R37, R38) or Resident Representative (RR) were issued a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) related to the end of Medicare A Skilled Services. This failure left the Residents and/or Resident Representatives uninformed of the possibility of continuing services and the expense that might be incurred.

Inspectors wroteBased on interview, record review, and admission packet review, the facility failed to ensure two of three residents (Resident (R)34, and R135) and/or their representatives reviewed for an emergent discharge to the hospital, out of a total sample of 17, were provided with a written notice of transfer that included all required information. The facility 's transfer notice forms did not include information on how to contact the Ombudsman or how to file an appeal, if desired. In addition, although transfer forms prepared by the facility may have been faxed to the hospital where the resident was being transferred, the facility failed to assure that both the resident and their representative received the forms. [...]

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure three of three (Resident (R) 135, 21, and R34) reviewed for hospitalization, the resident and/or their Resident Representative (RR) received a written bed hold notice upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital.

Inspectors wroteBased on record review, interview and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed and submitted for processing for three of 17 residents (Resident (R)35, R36 and R137) in the sample. This failure has the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the Minimum Data Set (MDS) assessment for one of 30 sampled residents (Resident (R) 33) was accurate. R33's MDS was not accurately coded to indicate the resident had experienced a significant weight loss. The failure to accurately code/assess the resident's condition has the potential to affect the care planning for the resident to receive all required services.

Inspectors wroteBased on interview, record review and review of Pre-admission Screening and Resident Review (PASARR) website, the facility failed to ensure one of four residents (Resident (R)6) admitted with a mental health diagnosis had a Level I PASARR for possible referral for a Level II screening to enable receipt of potential services. This failure increases the risk of residents with a mental health diagnosis not receiving specialized services.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure the care plan was updated for two of 17 residents (Resident (R) 33 and R135) reviewed. The failure to keep a care plan current could affect the appropriateness of care provided.

Inspectors wroteBased on interview and record review, the facility failed to investigate a fall incident for one of 17 residents (Resident (R) 135). The failure to identify a cause of the fall could result in a lack of effective interventions put into place and could result in additional falls and/or injuries.

Inspectors wroteBased on the record review and interview, the facility failed to monitor for behaviors and the effectiveness of the antidepressant medications for two of five residents (R) 19 and R30) reviewed for unnecessary medications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure antipsychotic medication was monitored for efficacy and side effects for one of five residents (Resident (R) 5) reviewed for unnecessary medications. R5 received Seroquel (an antipsychotic medication). The facility did not monitor R5 for possible side effects of the medication or response to the medication.

Inspectors wroteBased on observation and record review, the facility failed to ensure the required nursing staff posting accurately reflected the staff numbers and hours to care for the 56 current residents. This failure had the potential to inaccurately inform any resident, family member, or visitor to the facility of the available nursing staff caring for them, their loved one, or their friend.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff had access to, and were inserviced on, the facility's most recent abuse and neglect policies and procedures. In addition, the facility failed to ensure residents, family and/or guardians received copies of the facility's most recent abuse and neglect policies. The census was 67. Review of the facility's undated Resident Rights policy, given to all new residents in the resident handbook upon admission, showed: Definitions: -Abuse includes, but is not limited to, the willful infliction of physical, verbal, sexual, or mental anguish, or the willful deprivation by a caregiver or services necessary to maintain physical or mental health; -Neglect refers to the withholding of services from any person unable to provide for self the necessary services to maintain physical or mental health; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving one on one activities received those activities consistently. The facility identified seven residents as receiving one on one activities and problems were found with all seven (Residents #1, #4, #5, #10, #22, #39 and #54). The census was 67. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/14/19, showed: -Rarely/never understood; -Activity preference: Blank. Review of the resident's one on one activity log, dated 8/2019, showed the resident received one on one activities six times. Review of the resident's quarterly assessment, dated 8/12/19 at 12:46 P.M., showed the resident is on the one on one list for 2 visits a week. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to put interventions in place after two sampled residents incurred injuries; one being an abrasion to the head and the other a bruise to the thigh (Residents #1 and #9). Staff also left a set of keys with pepper spray unattended on the cooler in the kitchen for two of two days of observation. The census was 67. Review of the facility's undated Incident Investigation Procedure, showed: -In the event of any incident the following procedures must be implemented immediately: -Assess the person; -Provide medical attention as needed; -Contact the physician, inform, and receive order(s); -Contact the family or responsible party; -When an incident occurs, Charge Nurse must complete the Phase I investigation process by completing the Data Collection and Incident Report; -Phase I: -Complete Data Collection form; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure alternatives were attempted prior to the installation of side/bed rails and failed to thoroughly assess residents for risks of entrapment. Two of the 25 residents sampled had side/bedrails, neither had orders for side/bed rails, but utilized them. Problems were found with both (Residents #1 and #9). The census was 67. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/7/19, showed: -Diagnosis of dementia; -Short/long term memory loss; -Required extensive staff assistance for bed mobility, dressing, toileting and personal hygiene; -Required total staff assistance for transfers; -Incontinent of bowel and bladder; -No falls; -No side/bedrail use. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable accounting principles when the cash at the facility in the resident trust account at the end of the month exceeded the $50.00 allowable for cash on hand per medicaid resident. The census was 67. Review of the resident trust account on 9/24/19, showed: -The resident balance ledgers for January 2019, showed an ending balance of $18709.29. The cash on hand at the end of the month was $7580.40. The facility held funds for 51 residents which only allowed $2,550 cash on hand for petty cash; -The resident balance ledgers for February 2019, showed an ending balance of $19399.55. The cash on hand at the end of the month was $6909.40. The facility held funds for 51 residents which only allowed $2,550 cash on hand for petty cash; -The resident balance ledgers for March 2019, showed an ending balance of $18697.81. [...]

Inspectors wroteBased on interview, the facility failed to ensure residents received their mail on Saturdays. During the resident council meeting, nine of nine residents said they do not receive Saturday's mail until Monday. The census was 67. During the resident council meeting on 9/20/19 at 10:00 A.M., nine of nine residents attending said they do not receive their Saturday mail until Monday. They did not know why the mail was not delivered on Saturdays. During an interview on 9/20/19 at 11:40 A.M., the administrator said the mail carrier does not deliver the mail to the facility on Saturdays because they deliver the mail at different times and there might not always be someone at the facility to accept the mail. Normally, there is a receptionist on duty, from 7:00 A.M. until 8:00 P.M., on Saturdays that could accept the mail or a nurse could accept the mail.