Oak Manor Nursing and Rehabilitation Center Inc

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review, interview and facility policy review, the facility failed to ensure the medication error rate was less than five percent during the medication administration observation for two (Residents #57 and Resident #60) of four residents. This surveyor observed 31 opportunities for medication administration and four of the 31 medications were not administered in accordance with the Physician's Orders, resulting in a medication error rate of 12 percent.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure a Certified Nurse Aid (CNA #1) followed the Care Plan for the safety of one (Resident #3) of one resident whose Care Plans were reviewed. Specifically, the resident was transferred by one staff member instead of the required two, resulting in a fall.

Inspectors wroteBased on observations, interviews, facility document review, and facility policy review, the facility failed to discard 3 expired medications from 1 of 2 medication carts observed for medication labeling and storage standards.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure food was prepared in a safe manner in order to prevent foodborne illness by not cleaning the deep fryer and grease traps.

Inspectors wroteBased on observation and interview, the facility failed to ensure food stored in the walk-in refrigerator, the refrigerator/freezer in the Medication Room on the South Hall, the Nourishment Room on the Unit, and the Dry Storage Room were dated, labeled, and discarded promptly; kitchen appliances on the shelf below the deep fryer (can opener) and the ceiling vent were maintained in clean sanitary conditions for food preparation; expired food items were promptly removed/discarded by the expiration or use by dates; foods were dated when received to assure first in, first out usage; dietary staff washed their hands before handling clean equipment or food items; and hot food was maintained at or above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illnesses for residents who received meals from 1 of 1 kitchen. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure signs containing resident care instructions were posted in a manner to provide privacy and dignity for 2 (Resident #35 and #44) of 6 (Residents #22, #24, #33, #35, #44 and #50) sampled residents who had a low air loss mattress as documented on a list provided by the Director of Nursing (DON) on 08/08/23 at 2:10 PM, and staff members sat at eye level when assisting residents with meals for 1 (Resident #53) of 2 (Residents #33 and #53) sampled residents who required assistance with meals as documented on a list provided by the Administrator on 08/10/23 at 8:36 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure fingernails were trimmed, smooth, clean, and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #37) of 29 (Residents #1, #2, #3, #4, #9, #11, #14, #19, #22, #24, #26, #30, #32, #33, #34, #35, #36, #37, #38, #40, #41, #42, #44, #47, #48, #49, #50, #53 and #55) sampled residents who were dependent for nail care as documented on a list provided by the Administrator on 08/10/23 at 8:14 AM and facial and nose hair was removed to promote good personal hygiene and grooming for 1 (Resident #53) of 22 (Residents #2, #3, #4, #11, #14, #19, #22, #26, #30, #32, #33, #35, #37, #38, #40, #41, #42, #44, #49, #50, #53 and #55) sampled residents who were dependent for shaving as documented on a list provided by the Administrator on 08/10/23 at 8:00 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Physician Orders were followed for 1 (Resident #47) of 4 (Residents #19, #26, #47 and #50) sampled residents with orders for daily dressing changes.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen tubing, nasal cannulas, Continuous Positive Airway Pressure (CPAP) tubing, nebulizer tubing and mouth pieces/mask were properly changed, dated, and bagged in a closed container to prevent infections for 3 (Residents #11, #32 and #50) of 7 (Residents #1, #11, #32, #33, #36, #40 and #50) sampled residents who had a Physician Orders for respiratory treatments.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 6 residents who received pureed diets, and 20 resident who received mechanical soft diets from 1 of 1 kitchen (total census: 56) according to a list provided by the Dietary Supervisor on 08/10/23 at 10:33 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food was prepared by methods that maintained flavor and appearance to the residents to improve palatability and encourage good nutritional intake during 1 of 2 meals observed. The failed practices had the potential to affect 56 residents who received meal trays from the kitchen (total census: 56), as documented on a list provided by the Dietary Supervisor on 08/10/23 at 10:33 AM. The findings. 1. On 08/09/23 at 12:42 PM, the garlic bread served to the residents for lunch was too hard. The Surveyor asked Certified Nursing Assistant (CNA) #2 who was assisting residents in the Dining Room to describe the appearance of the garlic bread served to the residents. She stated, Bread is too hard. It's hard to break. 2. On 08/09/23 at 12:44 PM, the Surveyor asked a resident about the garlic bread served to her. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 6 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 08/09/23 at 10:33 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was disinfected after each use to prevent potential spread of infection for 2 of 2 observations (Residents #1 and #30).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident's personal fans was properly cleaned to prevent the potential for infection for 1 (Resident #11) of 3 (Residents #1, #11 and #48) sampled residents who used personal fans at the bedside and toiletries and elimination receptacles were bagged and labeled properly for 2 bathrooms on the Southeast (SE) Hall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident preferences listed on tray cards were followed for 1 (Resident #47) of 1 sampled resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure medications were not left unattended at the bedside, and all medications were in their original container, contained a pharmacy label and dated when opened in Medication room [ROOM NUMBER] and a medication cart.

Inspectors wroteBased on record review and interview, the facility failed to administer pneumococcal vaccines in a timely manner after receiving a signed consent for 1 (Resident #33) of 5 (Residents #11, #14, #19, #33 and #48) sampled residents whose immunizations were reviewed.