Oakhurst Health & Rehabilitation

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician or responsible party of a change in condition and/or need to alter treatment for two of seven residents, Residents #1 and #2.

Inspectors wroteBased on observation, staff interview and facility document review, it was determined that the facility staff failed to maintain a homelike environment on one of four unit hallways, the 300's hallway.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to promote a resident's highest level of well-being for two of seven residents, Residents #1and #2.

Inspectors wroteBased on observation, resident interview, clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to provide care and services to promote healing of a pressure injury (1) for one of seven residents in the survey sample, Resident #2.

Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to implement dietician recommendations for one of 7 residents in the survey sample, Residents #1.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to follow abuse prevention policies for reporting and thoroughly investigating a behavioral incident with an allegation of mistreatment for one of seven residents in the survey sample (Resident #201).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to report to the state agency and adult protective services, a behavioral incident with an allegation of mistreatment for one of seven residents in the survey sample (Resident #201).

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to thoroughly investigate a behavioral incident with an allegation of mistreatment for one of seven residents in the survey sample (Resident #201).

Inspectors wroteBased on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide timely incontinence care for one of seven residents in the survey sample (Resident #201).

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain a physician ordered urinalysis with culture for one of seven residents in the survey sample (Resident #201).

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from neglect by failure to provide timely identification and management of a pressure wound for one resident, Resident #4 (R4) in a survey sample of six residents, which deprived the resident of needed care to avoid physical harm of severe wound deterioration. by facility staff with regards to identification and treatment of a pressure ulcer until it was at an advanced stage and neglected to implement and treat a pressure ulcer for one resident, Resident #4 (R4) in a survey sample of six residents which resulted in harm for R4.

Inspectors wroteBased on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to identify a pressure ulcer until it was at an advanced stage, implement and treat a pressure ulcer for one resident, Resident #4 (R4) in a survey sample of six residents which resulted in harm for R4.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice with regards to the management of an advanced pressure wound for one resident (Resident #4-R4), constituting harm, and the timeliness of medication administration for three residents (Resident #2 -R2, Resident #3-R3, and Resident #4-R4), in a survey sample of six residents.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to serve meals at a temperature that was palatable to multiple residents eating in their rooms on 4 of 4 wings.

Inspectors wroteBased on observation, staff interview and facility documentation review, the facility staff failed to ensure food was distributed in a manner to prevent contamination in the main kitchen.

Inspectors wroteBased on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their infection prevention and control program by failure to implement precautions to prevent the transmission of diseases and infections in accordance with accepted national standards from the Centers for Disease Control and Prevention (CDC) for one resident (Resident #101-R101) in a survey sample of five residents.

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season, to 5 of 5 residents (Resident #6, 31, 3, 55, and 14) and 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled.

Inspectors wroteBased on observation, resident interview, facility staff interviews, and facility documentation review, the facility staff failed to maintain a safe, comfortable, and homelike environment on 1 of 4 nursing units and in the main dining room.

Inspectors wroteBased on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to review and revise the care plan for 2 of 22 residents (Resident #9 and #32) in the survey sample and failed to invite/involve 2 residents (Resident #6 and #25) in their care plan meeting.

Inspectors wroteBased on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain an accurate clinical record for one resident (Resident #25- R25) in a survey sample of 22 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) assessment for one of twenty-two residents in the survey sample (Resident #44).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to develop a care plan for three of twenty two residents. 1. Resident #49 (R49) was not care planned for the use of a hoyer lift (hydraulic equipment used to safely transfer residents). 2. R21 had an admitting diagnoses of PTSD (Post Traumatic Stress Disorder) and a care plan had not been developed. 3. R44 did not have a care plan for dental issues. The Findings Include: Diagnoses for R49 included; Acquired absence or right hip joint, osteoporosis, pathological left femur fracture, right knee replacement, and rheumatoid arthritis. The most current MDS (minimum data set - an assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 1/11/24. R49 was assessed with a cognitive score of 9 out of 15, indicating moderately impaired cognition. [...]

Inspectors wroteBased on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #22- R22) in a survey sample of 22 residents.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for two of twenty-two residents in the survey sample (Residents #1 and #3).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to administer medication according to physician orders for 1 of 22 residents (Resident #27).

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility failed to ensure parameters were put in place for supplemental oxygen for one of 22 residents. An oxygen order for resident #49 (R49) did not have a rate of delivery. The Findings Include: Accorning to the clinical record, diagnoses for R49 included Respiratory failure, asthma, chronic obstructive pulmonary disease, emphysema, and supplemental oxygen dependant. The most current MDS (minimum data set - an assessment tool) was a quarterly assessment with an ARD (assessment reference date) of 1/11/24. R49 was assessed with a cognitive score of 9 indicating moderately cognitively impaired. On 2/20/24 at 12:17 PM, R49 was observed with oxygen via nasal cannula being delivered at 2 liters per minute (LPM). When asked about the oxygen, R49 verbalized using it all the time. [...]

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review the facility staff failed to identify the specific trauma or triggers regarding post-traumatic stress disorder (PTSD) for 1 of 22 residents in the survey sample (Resident #21).

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide social services to assist with obtaining glasses for 1 of 22 residents (Resident #32).

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to respond to pharmacy recommendations for 1 of 22 residents in the survey sample (Resident #9).

Inspectors wroteBased on staff interview, and clinical record review, the facility staff failed to ensure one of 22 residents in the survey sample was free of unnecessary medications (Resident #9).

Inspectors wroteBased observation, facility documentation, and staff interview, the facility failed to accurately label open medication to ensure safe administration and storage. The Findings Include: The facility failed to ensure that a multi-dose vial of medication was labeled with a open date. On 2/21/24 at 11:16 a.m., an observation of the medication storage room was conducted on the nursing unit, in the presence of license practical nurse (LPN1), who provided access. An opened, multidose vial of the influenza vaccine was observed in the refrigerator. No open date was noted on the label. When questioned about this, LPN1 examined the medication, verbalized not seeing an opened date, and removed the medication from the refrigerator. On 2/21/24 at 11:30 a.m., when questioned further, LPN1 stated that an open date should be placed on the vial when medication is opened. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain physician ordered laboratory (Lab) services for one of 22 residents (Resident #38 - R38) in the survey sample; a CBC (Complete Blood Count) and A1C (Glycated Hemoglobin Test) were not collected as ordered for R38. The Findings Include: According to the clinical record, diagnoses for R38 included Diabetes, and kidney failure. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/19/24. R38 was assessed with a cognitive score of 6 out of 15, indicating moderately impaired cognition. Review of R38's physician order set documented an order, dated 6/24/23, for a CBC and A1C to be collected every three months on March 27th, June 27th, September 27th, and December 27th. [...]

Inspectors wroteBased on observation and staff interview the staff failed to ensure the survey results were readily accessible.

Inspectors wroteBased on staff interview and facility document review, the facility failed to provide sufficient nursing staff. Daily staffing logs evidenced low nursing staff during Christmas 2022. The Findings Include: Review of daily working logs (actual hours worked) for nursing staff revealed on 12/25/22 (Christmas day) the working shift from 7:00 AM through 7:00 PM consisted of two nurses and one certified nurses aide (CNA). Review of the scheduled for 12/25/23 indicated there were supposed to be two nurses and three CNA's. The schedule or any other documentation did not evidence what the census was on 12/25/23 in this 60 bed facility. However, documentation did evidence nurse staffing prior to Christmas day and after Christmas day had three nurses and up to 5 CNA's working. On 12/12/23 at 1:10 AM, CNA #1 (identified as the CNA working on Christmas day) was interviewed. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure an accurate clinical record for one of 7 residents. Resident #1 (R1) had an inaccurate activities of daily living (ADL) record. The Findings Include: Diagnoses for R1 included; seizure disorder, traumatic brain disorder, dementia, anxiety, and bipolar. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/1/23. R1 was assessed with a score of 10 indicating moderately cognitive impairment. Review of R1's clinical record in regards to a complaint indicated there were no entries made on the ADL record on day shift on 12/25/23 for eating, meal intake, and bowel and bladder elimination. On 12/12/23 at 1:10 PM, CNA #1 was interviewed. [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to provide adequate supervision and/or services to prevent accidents for 2 of 18 residents in the survey sample, Resident #48 and Resident #11. Resident #48 was not provided adequate monitoring/supervision, sustained an injury of unknown origin on his head that required 5 staples, resulting in harm. Resident #11 was not provided fall mats as required in her care plan.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review the facility staff failed to implement their abuse prevention policies regarding promptly reporting an injury of unknown origin to the state agency for 1 for 18 in the survey sample, Resident #48; and failed to follow their pre-employment screening policies for 13 out of 25 employees reviewed. Resident #48 was found with a medium size gash to the back of his head of unknown origin requiring 5 staples. This injury of unknown origin was not reported to the state survey agency or other local agencies as required by the facility's policy for abuse reporting/investigation.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to develop a comprehensive care plan for four of eighteen residents in the survey sample, Resident #31, #38, #46, and #11. Resident #31 was not care planned for self-administration of an albuterol inhaler; Resident #38 was not care planned for smoking; Resident #46 was not care planned for dental issues; and Resident #11 was not care planned with interventions for an existing pressure ulcer.

Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to ensure care in accordance with the resident's plan of care for 1 of 18 in the survey sample, Resident #27. Resident #27 was not weighed per facility standing orders, and to ensure that she was maintaining weight as directed in her care plan.

Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to store food in a sanitary manner in the main kitchen.

Inspectors wroteBased on observation, facility document review, staff interview and clinical record review, the facility staff failed to inspect a bed frame and mattress for possible entrapment risks for one of eighteen residents in the survey sample. Resident #11's bed, installed with a specialty air mattress for over 5 months, had not been inspected for entrapment risks. The facility's most recent bed inspections had no documented date of completion and did not include all facility beds in use.

Inspectors wroteBased on observation, resident interview, staff interview, clinical record review and facility document review, the facility staff failed to assess one of eighteen (18) residents for self-adminstration of medications, Resident #31. Resident #31 was observed with an albuterol inhaler at her bedside for self administration as needed. Resident #31 had not been assessed by the interdisciplinary team to ensure safe usage of the inhaler.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a safe, operational bed for one of eighteen residents in the survey sample, Resident #11. Resident #11 was in a bed with no functional controls to raise the head, foot or height of the bed.

Inspectors wroteBased on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure an injury of unknown origin was reported to the State Survey Agency and adult protective services for 1 of 18 in the survey sample, Resident #48. Resident #48 was found with a medium size gash to the back of his head of unknown origin requiring 5 staples.

Inspectors wroteBased on clinical record review and staff interview the facility staff failed to accurately completed a PASARR (Preadmission screening) for one of eighteen residents in the survey sample, Resident #46.

Inspectors wroteBased on observation, staff interview, and clincial record review, the facility staff failed to review and revise a comprehensive care plan for 1 of 18 in the survey sample, Resident #48. Resident #48's care plan was not revised for falls, including an injury of unknown origin.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to perform a pressure ulcer dressing change in a manner to prevent infection for one of eighteen residents in the survey sample, Resident #11. A nurse failed to perform hand hygiene and gloves changes during a dressing change to Resident #11's pressure ulcer.

Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed follow infection control practices with placement of urinary catheter bag for one of eighteen residents in the survey sample, Resident #11. Resident #11's catheter bag was observed in the floor beside the resident's bed.

Inspectors wroteBased on staff interview, clinical record review and facility documentation review, the facility staff failed to administer the COVID vaccine in a timely manner to one of 18 residents, Resident #27. Resident #27's Responsible Party consented to administration of the COVID vaccine on 06/04/2021, the vaccine was not given until 09/30/2021.

Inspectors wroteBased on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to provide necessary behavioral health care and services to maintain the highest practicable physical, mental and psycho-social well-being for one of 19 residents in the survey sample, Resident #59. In May of 2018, Resident #59 was assessed by the facility as having thoughts of self harm and an immediate threat to herself. The facility failed to develop a plan of care for the prevention of self harm, and Resident #59 was not provided with behavioral health care and services after this assessment. Resident #59 subsequently cut her wrist with a disposable razor and was sent to the hospital for treatment, resulting in harm.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure an accurate meal ticket for one of 19 residents in the survey sample. In addition, the facility failed to ensure a system for printing meal tickets in the facility that accurately reflected physician ordered therapeutic diets, food allergies and resident preferences. Resident #23, served a puree diet, had a meal ticket for a mechanical soft diet. The ticket documented the resident was served ground pork when puree turkey was actually served. The ticket indicated ground pork was served when ticket instructions stated No Pork. The facility had an unresolved issue with inaccurate meal tickets since April 2018.

Inspectors wroteBased on observation, staff interview, clinical record review, the facility staff failed to ensure a dignified dining experience during lunch observation for one of 19 residents in the survey, Resident #40. Resident #40, was identified as needing to be fed, was fed by a staff member who stood over the resident while feeding her.

Inspectors wroteResident #8 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: MS (multiple sclerosis), depression, anxiety, seizure disorder, bipolar disorder, neurogenic bladder, hypothyroidism, and hemiplegia. The most recent MDS (minimum data set) was an annual assessment dated [DATE]. This MDS documented the resident with a cognitive score of 13, indicating the resident was cognitively intact for daily decision making skills. This resident was assessed as requiring extensive assistance for most all ADLs (activities of daily living) with assistance of one staff and required total assistance for transfers and bathing with assistance of two staff. On 03/19/19 at 10:50 AM, Resident #8 was interviewed and stated that she had a complaint. The resident stated that an aide had stated to her hat she was going to punch the resident in the face. [...]

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to implement written policies and procedures for the prevention of abuse and investigation of abuse allegations, for one of 19 residents in the survey sample, Resident #8.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to report an allegation of sexual abuse to the state agency and/or officials in accordance with State law.

Inspectors wroteBased on resident interview, staff interview, clinical record review and facility document review, the facility staff failed to thoroughly investigate an allegation of sexual abuse for one 19 residents in the survey sample, Resident #8.

Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility staff failed to issue written notice of the bed-hold policy at the time of transfer for one of 19 residents in the survey sample. No written bed-hold notice was provided when Resident #109 was transferred to the hospital.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a PASARR (preadmission screening and resident review) was completed prior to admission to the facility for one of 19 residents in the survey sample, Resident 8.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan for three of 19 residents in the survey sample. 1. Resident #23 had no plan of care regarding use of plastic eating utensils due to unsafe behaviors. 2. Resident #29 had no individualized care plan developed regarding unsafe wandering and elopement prevention. 3. Resident #59 had no comprehensive plan of care regarding suicidal ideation.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to review and revise a comprehensive care plan for one of nineteen residents. Resident #20's care plan was not revised regarding code status.

Inspectors wroteBased on resident interview, clinical record review and staff interview, the facility staff failed to implement a bowel regimen program for one of 19 residents in the survey sample, Resident #26. Resident #26 stated that he had not had a bowel movement in 5 days and was uncomfortable.

Inspectors wroteBased on staff interview, clinical record review, facility document review and in the course of a complaint investigation, the facility staff failed to ensure supervision for the prevention of accidents for one of 19 residents in the survey sample, Resident #29. Resident #29, assessed as an elopement risk was not provided supervision and found outside of the facility on June 5, 2018 and November 28, 2018.

Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. Medication pass observations revealed three errors out of 39 opportunities resulting in a 7.6 % error rate.

Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 19 residents in the survey sample. Resident 109's closed clinical record did not include records of treatments/dressing changes provided for wound care and the resident's bathing records were incomplete.

Inspectors wroteBased on observation, staff interview and facility document review, the facility staff failed to follow infection control practices regarding hand hygiene during housekeeping; failed to implement infection control protocols for the prevention of Legionella and other water borne pathogens; and failed to follow infection control protocols during medication administration. A housekeeping staff member failed to perform hand hygiene after glove removal between cleaning of resident rooms and offices. The facility had no evidence of implementing maintenance and service items required in their water management program for the prevention of Legionella and other water borne pathogens. During a medication pass observation, a nurse dropped a medication on the top of the cart and then administered the medication to a resident.