Oakland Heights Nursing and Rehabilitation

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store food in accordance with professional standards for safety when: 1. Unlabeled and undated food was stored in the kitchen refrigerator. 2. Unlabeled and undated food was stored in the kitchen freezer. 3. Unlabeled, undated and beyond use by date for food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for 43 residents who received food from the kitchen and had access to use the resident refrigerator.

Inspectors wroteBased on observation, interview, record review, the facility failed to maintain a safe, comfortable and homelike environment when Resident 18's wall beside the right side of his bed had scattered areas of peeling paint. This failure had the potential to compromise the health and safety of the resident and could negatively impact the resident's psychological health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices were followed when upon inspection of the medication refrigerator, medications for the following discharged residents were found: 1. Eight packets of Veltassa 8.4 grams powder which belonged to Resident 154 (Veltassa is a medication used to correct the high potassium in the body. Potassium is a mineral that your body needs to work properly). 2. One Arexvy 120 micrograms kit which belonged to Resident 37 (Arexvy 120 micrograms kit contains two containers to be mixed to form a vaccine which is given to residents for the prevention of a lung infection caused by a virus called respiratory syncytial virus; a vaccine is a shot that trains your body's immune system to fight off a specific disease. Micrograms or mcg. is a form of measurement). 3. One Arexvy 120 mcg. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff were following isolation precautions to prevent the spread of disease for two of 16 sampled residents when: 1. A Licensed Vocational Nurse (LVN) did not use the proper personal protective equipment (PPE) while giving medications via gastrostomy tube (a gastrostomy is a surgical procedure that creates an opening in the stomach through the abdominal wall. A tube, called a gastrostomy tube is then inserted through this opening to provide nutrition and medication directly into the stomach) to a resident who was on enhanced barrier precaution (Enhanced Barrier Precautions are an infection control strategy that focuses on using gowns and gloves during high-contact resident care activities to reduce the transmission of infection). 2. [...]

Inspectors wroteBased on interview and record review , the facility failed to ensure the designated Infection Preventionist (IP is a professional who ensures healthcare workers and patients are doing all the things they should to prevent infections) had completed and received certification for specialized training in infection prevention and control program in accordance with the facility's policy and procedure and CMS (Centers for Medicare and Medicaid Services ) requirement. This failure resulted in the infection control and prevention program of the facility not having the benefit of a fully qualified and competent IP and possibly negatively affecting the quality of care provided to all residents.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to immediately report alleged abuse allegations to the California Department of Public Health (CDPH) within 2 hours, for one of one sampled resident (Resident 1), when Resident 1 alleged they were raped. This failure had the potential to cause a delay in investigations and affect physical and psychological well-being of resident 1. A review of Resident 1's admission Record printed 4/11/24, indicated Resident 1 was admitted to the facility in 2024 with a diagnosis of Traumatic Subdural Hemorrhage without loss of consciousness (a type of bleeding near your brain that can happen after a head injury). During a review of Resident 1 ' s Nurses Note, dated 4/7/24, the note indicated, Resident 1 notified staff on 4/6/24 at 11:30 p.m., they were raped. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure qualified staff carried out the functions of the food and nutrition services when the Registered Dietitian and the Certified Dietary Manager had minimal to no oversight of food received, stored, prepared, and served to residents. This failure had the potential to result in intake of an inadequate and/or a harmful amount of nutrients further compromising residents' medical status; and contamination of food leading to foodborne illness for 40 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu: 1. Met the nutritional needs of residents in accordance with established national guidelines; and; 2. Was followed when: a. Cheesecake was not served to residents on a modified textured diet. b. Cheesecake was not served to residents who were on a controlled carbohydrate (CCHO, a diet which has consistent amount of carbohydrate for each meal. This diet is typically prescribed for individuals who have difficulty with controlling blood sugars) diet. c. Penne pasta and chicken was not served for residents who were on a renal diet (diet that helps promote kidney health). d. Mixed baby green salad was not served to residents on a regular textured, and mechanical soft diet. e. Pureed pasta and pureed meatballs were served on a plate separately, rather than mixed together. f. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food at a palatable temperature. This failure had the potential to result in a decreased intake of food by residents leading to nutrition related medical complications for 40 residents who received food from the kitchen.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for safety when: 1. The inside of two ice machines were not maintained clean. 2. Fish was not thawed safely. 3. Fish was not stored safely. 4. Chicken held on trayline was not maintained at a safe temperature. 5. A food service staff was unable to properly calibrate thermometers. 6. Food was stored and available for use in the walk-in refrigerator past the use-by-dates and without identified use-by-dates. 7. Food stored in a reach-in freezer was not covered and had freezer burn. 8. Dry food stored in the dry storeroom was not protected from contamination. 9. Bulk, dry food storage bins containing bulk foods, were not maintained clean. 10. An industrial can opener was not maintained clean. 11. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the lid of an outside garbage dumpster holding food containers was closed. This failure had the potential to attract insects and rodents to the facility that housed 41 residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure a reach-in freezer was working in an efficient and safe manner in the way it was intended. This failure did not ensure food was stored in a way to promote food quality and food safety for 40 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) quarterly assessments for eight of 14 sampled residents (Residents 9, 11, 20, 23, 40, 47, 51, and 72). This failure had the potential to result in inaccurate assessments and improper interventions for Residents 9, 11, 20, 23, 40, 47, 51, and 72. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.) annual comprehensive assessments for two of 14 sampled residents (Residents 41 and 58). This failure had the potential to result in inaccurate assessments and improper interventions for Residents 41 and 58. During a review of Resident 41's admission Record dated 11/3/23, the record indicated Resident 41's recent admission date was 4/2023 and initial admission date was 11/2019, with multiple diagnosis including an admission diagnosis of Osteomyelitis of vertebra, sacral and sacrococcygeal region (an infection in spinal bone and lower spine). [...]

Inspectors wroteBased on observation, interview, and record review for two out of 26 sampled residents (Residents 20 and 40), the facility failed to ensure that services to maintain good hygiene was provided on a regular basis. Residents 20 and 40 were not given or offered shower or bed bath regularly. This failure had a potential to affect their health and feeling of well-being when basic and essential services were not provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 64), that care and services provided while on dialysis (treatment that helps the body remove extra fluid and waste products from the blood when the kidneys were not working) meet the needs to maintain healthy and safe. Resident 64's medications were given before dialysis days and post dialysis assessment were not consistently completed. These failures had a potential to affect the resident's health and safety due to decrease its effectiveness of medications and inconsistent monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 20), had routine dental services were provided to maintain good oral health. This failure had a potential to affect their health due to delay in obtaining necessary treatment due to lack of routine services provided.

Inspectors wroteBased on observation, interview, and record review for one out 26 sampled resident (Resident 20), the facility failed ensure that assistance and adaptive device were available during mealtimes. Resident 20's meal was served at bedside without assistance and adaptive equipment not readily available. This failure had a potential for Resident 20 to regress on their skills with using the adaptive equipment due to lack of consistency with its use.

Inspectors wroteBased on observation, interview and document review, Registered Nurse (RN 1) did not disinfect the blood pressure cuff, thermometer, and pulse oximeter between resident use for four ( Resident 1, 22, 41 and 91) of 7 sampled residents. This failure had the potential for the transmission of communicable diseases and infection.

Inspectors wroteBased on observation, interview and document review, the facility failed to manage the nutritional needs for one (Resident 2) of 4 sampled residents with kidney failure receiving dialysis treatment (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) and transferred from the hospital for a leg fracture and management of wounds. This failure had the potential for Resident 21 to not receive the right amount of nutrients to help build muscle, repair wounds and fight infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and store food under sanitary conditions when: 1. Refrigerated food without month, date, and year available for use: a. Mayonnaise and salad dressing. b. Green and white substance on a lemon found in a box of lemons. 2. Open container of soy sauce 3. Spices were not labeled with date received, opened or expiration date. This failure had the potential to place the residents at risk for developing foodborne illness.