Oak River Rehab

Inspectors wroteBased on Interviews and record review, the facility failed to meet this requirement when Resident 1 was administered nitroglycerin without a physician ' s order. This was against the facility ' s policy and had the potential to contribute to a decline in Resdident 1 ' s health. Findings Resident 1 was admitted to the facility on [DATE] for diagnoses that included metabolic encephalopathy, (an imbalance of chemicals in the blood that can cause confusion and tiredness), morbid (life-threatening) obesity, muscle weakness, congestive heart failure (inability of the heart to return blood flow to the body), history of stroke, and hypertension (high blood pressure). Review of the facility ' s policy titled Administering Medications, revised April 2019, indicated that physician orders are required for administering medications to residents:4. [...]

Inspectors wroteBased on interview, record review, facility document, and facility policy review, the facility failed to ensure residents' Preadmission Screening and Resident Review (PASARR) Level I Screenings were accurate for 2 (Resident #76 and Resident #111) of 3 residents reviewed for PASARR requirements. This had the potential for residents not to receive care and services in the most integrated setting appropriate to their needs and adversely affect their psychosocial and emotional well-being.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure medication was ordered from the pharmacy within enough time to ensure routine doses were available for administration to 1 (Resident #116) of 5 residents reviewed for medication availability. This had the potential for residents not to receive medications as their physician's ordered and negatively impact their physical and emotional well-being.

Inspectors wroteBased on observation, interview, record review, facility procedure review, and facility policy review, the facility failed to provide catheter care in a manner to prevent cross contamination and potential infection for 1 (Resident #57) of 1 resident observed for urinary catheter care. This had the potential to contribute to Resident 57 developing unnecessary urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents, and appropriate post fall or post accident care for two of 5 sampled residents (Residents 19 and 81), with a history of falls, when: 1. Resident 19 had five falls within two-months. Neuro (neurological assessments include mental status, motor function, pupillary responses and vital signs) checks were not done according to the facility policy for any of the five falls (all of which were unwitnessed, or the resident hit her head), interventions in the care plan were not implemented during the fall on 1/12/22, post fall injuries sustained on 2/17/22, were not monitored according to the care plan, and the falls care plan was not updated with appropriate interventions, relating to the cause of the falls, which occurred on 1/18/22, 2/17/22, and 3/10/22. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents were treated with respect and dignity when one resident (Resident 300), was observed with their backside exposed in the hallway. This failure could lead to this resident feeling exposed, and embarrassed which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans for 2 of 25 sampled residents (Resident 61, and 81), when: 1. Resident 61 did not have a behavior care plan developed for the use of Seroquel and Zyprexa (both antipsychotic medications, that alter mood and behavior). 2. Resident 81 did not have an accident care plan developed when she hit her chin on her bedrail, and sustained a bruise. These failures had the potential for important medical and emotional services that these residents needed, to go unrecognized and untreated which could lead to negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the comprehensive care plan was implemented for one of 25 sampled residents (Resident 6), when the physician orders for use of a topical cream were not followed and wound treatment was noted to have continued after the wounds were healed. This failure resulted in Resident 6 receiving a medicated cream, in error, and inaccuracies in the medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 5 sampled resident's medication regimen was free from unnecessary drugs when Resident 61 was given Seroquel (an antipsychotic drug that alters mood and behavior) without monitoring the correct indication for use. This had the potential for Resident 61, and his physician to receive incorrect information regarding the effectiveness of the drug and negatively impact Resident 61's psychosocial and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe storage, and labeling of medications and medical supplies when: 1. A mislabeled blister pack (a package that is pre-filled with medication by a pharmacy) for a pain medication called tramadol (also known as Ultram, a medication to relieve pain)was not consistent with current doctor's order in one out of four sampled residents (Resident 51). 2. Expired medication, and blood test supplies were stored in the active storage areas in one of two medication rooms. This failure resulted in the potential for unsafe medication use, and inaccurate lab test results in the facility which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the correct psychotropic (affects mind, emotions, behavior) medication for the exhibited behavior per physican order for one of one five sampled residents (Resident 27). This resulted in Resident 27 to receive an unecessary psychotropic medication for four months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their menus and measure portion sizes correctly for residents receiving Controlled Carbohydrate (CCHO-an eating plan designed to help regulate blood sugar; carbohydrate--food that provides energy) diets during lunch. This had the potential to prevent 32 residents who received a CCHO diet from getting the proper amount of food to meet their nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently follow their Nutritionally Enhanced Meal (NEM-added extra calories or protein) plans during breakfast. This failure had the potential to prevent some residents from receiving the nutrition needed to maintain their weight and health which could have negatively affected their well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet food safety requirements when: 1. the kitchen ice machine sanitizer solution was not checked for concentration before use; 2. nutritional supplement shakes stored in the refrigerator were not dated when pulled from the freezer and the temperature of the shakes was 44.2 degrees Fahrenheit (F.); 3. nursing staff did not sanitize their hands between residents when handing out plates of food in the dining room; 4. a plastic scoop was stored inside a container of dry goods during use; 5. kitchen staff did not follow the facility's policy on facial jewelry and beard covers. These practices had the potential to cause harm to all residents by putting them at risk for eating food contaminated by germs or chemicals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe operating condition when two gaskets (seals) on refrigerator doors were broken. This failure could have caused food to not be stored at safe temperatures. Improper temperatures could have caused a growth of germs in the food that potentially could lead to food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's written plan of care for two of 25 sampled residents (Residents 26 and 37) when: 1. The facility did not give the ordered amount of tube feeding for Resident 37. This had the potential to result in additional weight gain. 2. The facility did not give a medication with food as ordered by the physician. This had the potential to cause stomach distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents using oxygen (O2), have continuous oxygen applied as ordered by the physician (Resident 81). This failure had the potential that residents could suffer with inadequate oxygenation and respiratory distress and/or shortness of breath (SOB).

Inspectors wroteBased on observation, interview, and record review, the facility pharmacy and nurses failed to provide an accurate label for one of one sampled resident receiving IV (Intravenous) medications (Resident 105) when the label had two conflicting infusion rate directions that would result in the medication being delivered over 30 minutes or 60 minutes depending on how the directions were interpreted. This failure had the potential for the medication to be administered at inconsistent infusion rates and at a rate other than prescribed, as well as resident frustration at the inconsistent length of time to administer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of a lancet (a device used for obtaining blood from a finger), that was contaminated with blood, into a sharps container (a plastic container that prevents access after disposal) and instead discarded the contaminated lancet into a the residents shared bathroom garbage can for one of two tests observed during survey (Resident 123). This failure had the potential for anyone handling the garbage to be subjected to a sharps injury and disease from blood borne illness.