Oak Village

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement resident's plan of care based on current status for 1 of 1 resident reviewed for pressure ulcers, 3 of 5 residents reviewed for accidents, and 1 of 5 residents reviewed for unnecessary medications. A resident lacked a care plan for a current stage 3 pressure ulcer, lacked a care plan for behavior of cannabis smoking, lacked a care plan for antiplatelet medication, and not following fall interventions. (Resident 28, Resident 9, Resident 1, Resident 30, Resident 5)

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were revised to reflect current status for 1 of 1 residents reviewed for pressure ulcers and 3 of 5 residents reviewed for unnecessary medications. A resident's pressure ulcer care plan had not been discontinued when the area healed, resident's care plans reflected current use of a discontinued medications, a fall care plan was not revised to include current interventions, and a current diagnosis of shingles and pneumonia that were no longer active (Resident 28, Resident 4, Resident 30, Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment for all residents for 3 of 3 random observations. The resident's oxygen tubing was dragging on the ground, the urinary catheter bag and tubing were dragging on the floor, and clean linens were carried against a staff member's uniform shirt. (Resident 4, Laundry 9, Resident 23)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure transportation was provided for a resident to get to her neurologist appointments for 1 of 2 residents reviewed for transportation. A resident receiving Botox injections for her Multiple Sclerosis (MS) missed two appointments due to not having transportation. (Resident 9)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure behavior monitoring for 1 of 1 residents reviewed for behavior concerns. A resident's behaviors were not monitored, tracked, or treated leading to an escalation of behaviors. (Resident 2)

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of residents for 1 of 5 residents reviewed for unnecessary medications and 1 of 2 closed records reviewed. Medications were not available to be administered as prescribed. (Resident 4, Resident 18)

Inspectors wroteBased on the interview and record review, the facility failed to ensure its smoking policy was implemented for 2 of 2 residents reviewed for smoking. Resident's smoking evaluations were not completed quarterly. (Resident 9, Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations and failed to complete hand hygiene during meal service. Food was stored in a reach in freezer in the kitchen open to air, undated, and unlabeled. The kitchen equipment and spaces contained dust and debris, and the staff failed to complete hand hygiene after coming in contact with residents while assisting in the dining room. (Resident D, Resident F, Resident G)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and appropriate medication administration practices were in place for 1 of 3 residents reviewed for pharmaceutical services. A resident received another resident's medications after the administering nurse preset residents' medications prior to the medication pass. (Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appetizing and palatable meals for 1 of 1 lunch trays sampled on 1 of 2 halls. Residents complained of cold food temperatures and unappetizing food during meals. (100 hall, Resident J, Resident M, Resident P)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations. Food was stored in a reach in freezer in the kitchen open to air, and refrigerated and frozen foods were not labeled and dated.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate controlled drug records were maintained regarding the dispensing and administration of controlled drugs for 1 of 3 residents reviewed for pharmaceutical services. Controlled substance count sheets did not match the documented administration of controlled drugs during a 30 day review period. (Resident B)

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide activities when the Activity Director was out of the building for 6 of 7 residents reviewed for activities (Residents 2, 10, 25, 13, 3, and 12).

Inspectors wroteBased on record review and interview, the facility failed to ensure post dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are no longer able to function properly) vital signs were documented for 1 of 1 residents reviewed for dialysis (Resident 13), and failed to ensure the administration of medications had been documented in the medication administration records (MAR) for 4 of 12 residents MARs reviewed (Resident 25, 2, 10, and 12).

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was created for dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with daily life and activities) for 1 of 1 residents reviewed for Preadmission Screening and Resident Review (PASRR) (Resident 2), and failed to ensure a person-center dementia care plan interventions were in place for 1 of 1 resident reviewed for dementia care (Resident 21).

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were conducted quarterly for 3 of 16 residents reviewed for care plan meetings (Residents 3, 6, and 12).

Inspectors wroteBased on record review and interview, the facility failed to ensure there was not a delay in treatment for a resident who had a fall with complaints of pain and discomfort for 1 of 1 resident reviewed for delay in treatment (Resident 18).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident had adequate pain control during a pressure ulcer dressing change for 1 of 1 reviewed for pain management (Resident 18).

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure expired medications were disposed of properly for 1 of 2 medication carts and 1 of 1 medication storage rooms reviewed for medication storage (Resident 3).

Inspectors wroteBased on observation and interview, the facility failed to ensure facial hair restraints were used for 2 of 2 kitchen observations.

Inspectors wrote2. On 8/21/23 at 11:02 A.M., the shared bathroom (shared with Resident 18, Resident 26, and Resident 28) between room [ROOM NUMBER] and room [ROOM NUMBER] was observed with two toothbrushes face down in a cup with a tube of toothpaste, all unlabeled. An uncovered emesis basin was observed sitting on the back of the commode, and an uncovered wash basin was observed sitting on the floor under the sink. On 8/25/23 at 11:59 A.M., the same was observed. At that time, Certified Nurse Aide (CNA) 36 indicated the toothbrushes should have been labeled, and was not sure how they should be stored. On 8/22/23 at 11:17 A.M., Resident 18's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety, stroke, and depression. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Minimum Data Set (MDS) assessment was completed for 2 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for missing personal property. The MDS failed to indicate one resident received 7 days of an antidepressant, one resident received 7 days of a diuretic and had a bed alarm, and one resident had a bed and chair alarm. (Resident 19, Resident 12, Resident 20)

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assist a resident in a [name of lift] lift and prevent falls for 1 of 4 residents reviewed for hospitalizations. A staff member failed to use the handles on the lift which caused the lift to tip over with the resident in the lift pad.(Resident 27)

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments were completed for each resident to evaluate and address nutritional needs on a regular basis for 3 of 3 residents reviewed for nutrition. The Registered Dietitian did not complete evaluations quarterly or with a change of condition. (Resident 18, Resident 27, Resident 28)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent (%) for 2 of 6 residents (Residents 11, and Resident 4) observed during medication pass. Two medication errors were observed during twenty-seven opportunities for error in medication administration. This resulted in a medication error rate of 7.41%.