Oakdale Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 63. Review of the facility's policy titled, Cleaning Schedule, dated February 2012, showed: - There will be a written, comprehensive cleaning schedule posted and monitored to maintain the cleanliness and sanitation of the food service department;- The food service manager is responsible for developing a cleaning schedule for the department, he/she will also monitor compliance and overall cleanliness and sanitation of the department;- The cleaning schedule will include each piece of equipment for the specific position assigned to complete the task, frequency of cleaning; i.e. [...]

Inspectors wroteBased on interview and record review, the facility failed to limit the use of as needed (PRN) psychotropic (medications that affects a person's mental state) medication orders for 14 days for one resident (Resident #29), and failed to ensure an appropriate diagnosis for the use of an antipsychotic (medication that treats mental disorders characterized by a disconnection from reality) medication for one resident (Resident #19) out of three sampled residents. The facility census was 63. Review of the facility's policy titled, Psychotropic Medication Use, dated December 2018, showed:- It is the policy of the facility that all residents receiving psychotropic medications be monitored to ensure the least amount of medication is given to treat the diagnosis;- PRN orders for psychotropic drugs are limited to 14 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed for two residents (Residents #11 and #57) for one medication cart out of two sampled medication carts. This had the potential to affect all residents. The facility's census was 63. Review of the facility's policy titled, Medication Storage In The Facility, dated June 2020, showed:- Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock by the facility. 1. Observation of the Certified Medication Technician (CMT) medication cart on 02/10/26 at 2:45 P.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Food Labeling, revised January 2012, showed: - Foods must be properly labeled; - Write time and date of preparation on a label and place on the container. The facility did not provide policies regarding kitchen cleaning, meal carts, or covering of foods. 1. Observation on 10/21/24 at 9:28 A.M., and 10/22/24 at 8:59 A.M., of the kitchen showed: - No cleaning logs; - Scattered debris below the food preparation table on the shelf under the table; - Cooking sheet attached to the stove separating the fryer and the cooking stove to be dirty and covered in grease; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when one resident (Resident #49) out of one sampled resident transferred to the hospital. The facility census was 55. Review of the facility's policy titled, Making an Emergency Transfer or Discharge, dated December 2016, showed: - Notify the receiving facility; - Prepare the resident; - Prepare a transfer form to send with the resident; - Notify the resident representative; - The policy did not address notification in writing to the resident or the resident representative. 1. Review of Resident #49's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/16/24, and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident, family, and/or legal representative of their bed hold policy in writing at the time of transfer to the hospital for one resident (Resident #49) out of one sampled resident. The facility's census was 55. The facility did not provide a policy related to bed hold notification. 1. Review of Resident #49's medical record showed: - Transferred and admitted to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident or the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive discharge summary for one resident (Resident #54) out of one discharged resident. The facility's census was 55. The facility did not provide a policy regarding a discharge summary or recapitulation. 1. Review of Resident #54's closed medical record showed: - Resident discharged home on [DATE]; - No documentation of a discharge summary or recapitulation. During an interview on 10/24/24 at 10:11 A.M., the Administrator said there was no discharge or recapitulation done for the resident. It should have been done. Social services was responsible for this and discharge planning should be started as soon as the residents were admitted . During an interview on 10/24/24 at 11:00 A.M., the Social Services Designee said the resident didn't get the discharge summary or recapitulation did but should have. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a urinary catheter (a tube inserted into the bladder to drain urine) drainage bag and tubing was kept off the floor for two residents (Residents #9 and #21), failed to cover a urinary catheter drainage bag with a dignity bag for one resident (Resident #21), and failed to ensure proper urinary catheter placement when staff raised the catheter drainage bag and tubing above the level of the bladder for one resident (Resident #9) out of two sampled residents. The facility census was 55. Review of the facility's policy titled, Catheter Care, Urinary, revision date July 2017, showed: - Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of Resident #9's medical record showed: [...]

Inspectors wroteBased on observation and interview, the facility staff failed to post the required daily nurse staffing information which included the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, in a prominent location readily accessible to residents and visitors. The facility census was 55. Review of the facility policy titled, Daily Staffing Information, dated July 2014, showed: -It is the policy of the facility, as required by Centers for Medicare and Medicaid Services (CMS), to post daily staffing information in the facility. This must be posted in a prominent place, readily accessible to residents and visitors at the start of each shift; - Staffing is to be posted daily utilizing a standardized form that includes the facility name, current date, total number of staff and actual hours worked; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 55. Review of the facility's policy titled, Insulin Pen Injection Administration, dated June 2020, showed: - Follow manufacturer instructions for expiration dating. Review of Lantus (a type of insulin) manufacturer's insert, dated 08/2022, showed to discard the Lantus pen after 28 days of opening, even if it has insulin in it. 1. Observation on 10/23/24 at 10:02 A.M., of the nurse medication cart showed two Lantus pens labeled with an opened date of 09/21/24, 32 days after opening. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dumpster was closed at all times and maintained to keep pests out and/or to keep the garbage contained in the dumpster. The facility census was 55. The facility did not provide a policy in regards to the dumpster. Observations of the outside trash dumpster showed: - On 10/21/24 at 11:33 A.M., the dumpster lid opened with three bags above the top of the dumpster opening; - On 10/21/24 at 3:00 P.M., the dumpster lid opened; - On 10/22/24 at 9:30 A.M., the dumpster lid opened. Staff walked with a cart of trash, placed the trash in the dumpster, and did not close the dumpster lid; - On 10/22/24 at 10:10 A.M., the dumpster lid opened; - On 10/22/24 at 12:49 P.M., the dumpster lid opened; - On 10/23/24 at 11:00 A.M., the dumpster lid opened; - On 10/24/24 at 8:30 A.M., the dumpster lid opened; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use proper infection control techniques during incontinent care for four residents (Residents #9, #21, #48 and #205) out of four sampled residents and one resident (Resident #3) outside the sample. The facility failed to properly store trash and regulated medical waste boxes filled with biohazard material. The facility also failed to use proper infection control techniques during trash disposal. The facility census was 55. Review of the facility policy titled, Handwashing, dated April 2015, showed: - It is the policy that all staff thoroughly cleanse hands with friction, soap, and water to control infection and reduce transmission of organisms; - Hands should be thoroughly washed before and after providing resident care. Review of the facility policy titled, Perineal Care, dated July 2017, showed: [...]

Inspectors wroteBased on record review and interviews, the facility failed in prevention of communicable disease in regard to Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough and difficulty breathing) screening for two residents (Resident #22 and #50) out of five sampled residents. Also, the facility failed to implement a risk management process specific to Legionnaires' disease (a serious type of pneumonia caused by legionella bacteria) which had the potential to affect all residents, staff and the public. The facility's census was 59. The policy, Tuberculosis Testing, last revised April 2015, showed: - Within seven days of admission, each resident will receive a two-step Mantoux (a test that uses a liquid called tuberculin, that is injected just below the skin, causing a small, pale bump to appear and is read within 48-72 hours) test; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility's census was 59. Review of the facility's policy, titled QAPI, revised October 28, 2020, showed: - All department managers, the administrator, the director of nursing, medicare coordinator/designee, infection control and prevention officer, medical director, consulting pharmacist, resident and/or family representatives (if appropriate), and three additional staff members will provide QAPI leadership by being on the quality assessment and assurance (QAA) committee. 1. Review of QAPI Meeting information, dated 02/21/22 and provided by the Administrator, showed the following members attended: - Administrator; - Director of Nurses; - Assistant Director of Nurses; - Infection Preventionist; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNF ABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) Form 10055 for one resident (Resident #164 ) out of three sampled residents who remained in the facility when benefits were not exhausted, and failed to issue a CMS Notice of Medicare Non-Coverage (NOMNC: Medicare requires SNFs to issue a NOMNC to beneficiaries no later than two days before covered services end) Form 10123 for two residents (Resident #163 and #164) out of three sampled residents. The facility's census was 59. 1. Review of Resident #163's NOMNC form showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS, a federally mandated assessment to be filled out by the facility staff) assessment within 14 days of a resident admitted to hospice. This affected one resident (Resident #34) out of three sampled residents. The facility census was 59. Review of the facility's policy titled, Resident Assessment Instrument (RAI), revised November 2017, showed: - A comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the RAI specified by CMS (Centers for Medicare and Medicaid Services) and shall be made within fourteen (14) days of the resident's admission; [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs for three residents (Residents #8, #41, and #59) out of 15 sampled residents. The facility census was 59. The facility failed to provide a policy regarding comprehensive care plans. 1. Review of Resident #8's face sheet showed: - admitted on [DATE]; - Diagnoses included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), schizoaffective disorder (a mental health problem including psychosis as well as mood symptoms), violent behavior, and unspecified mood disorder. Review of the resident's quarterly oral cavity observation on 07/31/23 showed mouth pain and broken/loose teeth and/or caries (cavities). [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individual needs for one resident (Resident #14) out of 15 sampled residents. The facility census was 59. Review of the facility's policy titled, Resident Assessment Instrument (RAI), revised November 2017, showed: - A comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences, using the RAI specified by CMS (Centers for Medicare and Medicaid Services) and shall be made within fourteen (14) days of the resident's admission; - The interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) must develop, review and update the care plan when the resident has been readmitted to the facility from a hospital stay. 1. [...]

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders for one resident (Resident #57) out of 15 sampled residents. The facility's census was 59. Review of Resident #57's medical record showed: - A diagnosis of venous thrombosis (a condition that occurs when a blood clot forms in a vein) and embolism (sudden blocking of an artery); - An order for Eliquis (medication used to treat and prevent blood clots and stroke) 5 milligrams (mg), give one tablet twice daily for venous thrombosis and embolism, dated 03/27/23; - A Note to Attending Physician/Prescriber from the Consulting Pharmacist to reduce medication to 2.5 mg twice daily for prophylaxis or discontinue, signed in agreement by the attending physician and dated 06/17/23; - No clarification from the attending physician on whether to reduce the dose or discontinue the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and complete smoking assessments upon admission and quarterly for three residents (Resident #6, #14, and #41) out of 15 sampled residents and one resident (Resident #55) outside the sample. The facility census was 59. Review of the facility's policy titled, Smoking Policy and Procedure, dated 10/21/22, showed: - Any resident that expresses an interest to smoke will be assessed at the time of admission and at least quarterly or with any significant change to determine the level of assistance and supervision needed for resident safety. This includes e-cigarettes (battery powered device that provides vaporized nicotine solution); - Based on the assessment findings, the resident's plan of care will be revised to reflect the level of assistance or supervision needed to ensure resident safety; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to limit the use of an as needed (PRN) antipsychotic medication (a medication to treat a mental disorder characterized by a disconnection from reality) to 14 days or to document the rationale for extending the order for one resident (Resident #59) out of 15 sampled residents. The facility census was 59. 1. Review of Resident #59's Face Sheet showed: - Diagnoses of senile degeneration of the brain (decrease in the ability to think, concentrate, or remember), Alzheimer's with early onset (disease that destroys memory and other important mental functions occurring prior to the age of [AGE] years old) and unspecified mood (affective) disorder (general emotional state or mood is distorted or inconsistent with circumstances). Review of the resident's Physician's Orders showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents. The facility census was 59. Review of the facility's policy titled Medication Storage in the Facility, dated [DATE], showed: - Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations; - Medication requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator; - Outdated drugs will be immediately withdrawn from stock by the facility. They will be disposed of according to drug disposal procedures, and reordered from pharmacy if a current order exists; - Temperature sensitive drugs will be properly stored at the facility. [...]