Oak Woods Home for the Elderly

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents have the right to be free from any chemical restraints by having PRN orders for psychotropic drugs exceeding the 14 day limit for 2 (#1 and #7) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#2, #42, #57) of 3 residents reviewed for activities of daily living.

Inspectors wroteBased on record review and interview, the facility failed to ensure it provided routine drugs and biologicals to its residents by failing to have a medication available for administration for 1 (#57) of 2 residents observed during a medication pass.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by 1) failing to monitor the heart rate with the administration of metoprolol succinate for Resident #1 and 2) failing to obtain a lipid panel as ordered for Resident #1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that its medication error rates are not 5 percent or greater by having a medication error rate of 17% for 2 (#57, #58) of 2 residents observed for a medication pass.

Inspectors wroteBased on observations, interviews and record reviews, the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to 1) implement enhanced barrier precautions for 1 (#6) of 1 residents reviewed for enhanced barrier precautions and 2) follow facility policy for the cleaning, storage and replacement of piston syringes for 1 (#26) of 1 residents reviewed for tube feedings.

Inspectors wroteBased on record review and interview, the facility failed to ensure each resident was assessed using the quarterly review instrument approved by CMS not less frequently than once every 3 months by failing to ensure a quarterly MDS was completed timely for 1 (#18) of 1 residents reviewed for resident assessments.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies, and skill sets necessary to care for resident needs by having a nurse leave prescription medications at Resident #30's bedside unattended for 1 (#30) of 1 residents reviewed for nurse competency.

Inspectors wroteBased on record review and interview the facility failed to accurately submit mandatory direct care staffing information, based on payroll, to Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30).

Inspectors wroteBased on record review and interview the facility failed to ensure appropriate treatment and services were provided to prevent potential complications from enteral feeding by failing to record feedings and water flush amounts for 1 (#7) of 2 (#7 and #22) residents reviewed for tube feedings.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide respiratory care consistent with professional standards for 4 (#2, #18, #35, #22) of 4 (#2, #18, #35, #22) sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was: 1) stored properly for resident #2, #18, #35, and #22, 2) changed in a timely manner for resident #2 and #35 and, 3) dated for resident #2 and #18.

Inspectors wroteResident #18 Review of the medical record for resident #18 revealed an admit date of 05/02/2023with diagnoses of essential hypertension, paroxysmal atrial fibrillation, generalized osteoarthritis, and unspecified dementia with behavioral disturbance. Review of the annual MDS assessment dated [DATE] revealed resident #18's BIMS score was 99, which indicated they were unable to complete the test. Further review of the MDS revealed she was dependent on staff for all activities of daily living. Review of the February 2025 physician orders revealed an order dated 01/31/2025 that resident #18 may use bilateral quarter rails to aide in bed mobility. Review of the current care plan revealed resident #18 required quarter bed rails. Interventions included that resident #18 may use bilateral quarter rails to assist with turning and repositioning. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to ensure there was sufficient staff available at all times to provide nursing and related services to meet the resident's needs and safety in a manner that promotes each resident rights, physical, mental and psychosocial well-being. The facility failed to ensure there was sufficient staff on 07/21/2024, 07/28/2024 and on 08/31/2024 to provide care and services to the residents residing in the facility.

Inspectors wroteBased on observations and interview the facility failed to ensure the nurse staffing data was posted daily. The facility failed to ensure the nurse staffing data was readily accessible to residents and visitors.

Inspectors wroteBased on record reviews and interviews, the pharmacist failed to identify and report irregularities to the attending physician, the facility's medical director and director of nursing (DON) for 2 (#8 and #19) of 6 (#2, #8, #19, #24, #46 and #154) residents reviewed for unnecessary medications.

Inspectors wroteResident #8 Review of the medical record revealed resident #8 received the blood thinner Clopidogrel 75mg daily with a supporting diagnosis of cerebral infarction. Review of resident #8's medication administration record revealed there was no documentation that the facility was monitoring the resident for bleeding. On 02/03/2025 at 4:00 p.m., interview with S2DON confirmed there was no recorded monitoring for bleeding related to resident #8. Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to 1) monitor edema for a resident who received a diuretic for 2 (#2, and #19), and 2) monitor for bleeding for a resident who received an anticoagulant for 3 (#8, #19 and #46) of 6 (#2, #8, #19, #24, #46 and #154) residents reviewed for unnecessary medications.

Inspectors wroteBased on observations the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The failed practice was made evident by uncleanliness of the kitchen which included the food storage areas, meal serving area, cooking areas and the three compartment sink.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and help to prevent the development and transmission of communicable diseases and infections by failing 1) to have signage on residents' doors that were COVID positive and/or Enhanced Barrier Precautions (EBP) that included specific personal protective equipment (PPE) required for staff use for 4 (#35, #43, #47, and #154), and 2) to ensure indwelling catheter tubing was not touching the floor for 2 (#35 and #154) of 5 (#14, #35, #43, #47, and #154) residents reviewed for infection control.

Inspectors wroteBased on observation and interview, the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance from toileting facilities. The failed practice was evidenced by a public bathroom having a call light pull cord wrapped around a grab bar which prevented it from being available to activate if a resident needed to activate the call light from the floor.

Inspectors wroteBased on record reviews and interview, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) not less frequently than once every 3 months for 2 (#36, #46) of 2 (#36, #46) residents reviewed for resident assessment out of a total of 18 sampled residents.

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents by failing to implement a new intervention following a fall for 1 (#51) of 2 (# 24, #51) residents reviewed for falls.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain grooming and personal and oral hygiene for 2 (#42 and #201) of 2 sampled residents reviewed for activities of daily living. The facility failed to ensure Resident #42's fingernails were cleaned and trimmed in a timely manner and the facility failed to provide oral care for Resident #201.

Inspectors wroteBased on record review and interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid (CMS) system in a timely manner for 3 (#6, #18, & #25) of 5 (#6, #18, #25, #26, & #37) residents reviewed for the timeliness of MDS submissions.

Inspectors wroteBased on record review and interviews, the facility failed to develop a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (#201) of 1 sampled resident who was recently admitted .