Oakland Manor

Inspectors wroteBased on observations, record review, facility investigative file review, resident and staff interviews and facility policy review the facility failed to ensure 5 of 5 residents (Resident #1, #2, #3, #4, and #5) were free from misappropriation of their medication. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the State Agency no later than 2 hours after the allegation of abuse was suspected. The facility reported a census of 33 residents.

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to store narcotics to minimize loss when 1 of 3 residents (Resident #1) discontinued narcotic pain medication remained in the medication cart for almost 6 months. This resulted the in pills being misappropriated by a facility staff member. The facility reported a census of 33 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to accurately document a skin assessment for 1 of 3 residents (Resident #1) reviewed with a pressure ulcer. The facility also failed to complete proper hand hygiene while completing a treatment to Resident #1's pressure ulcer. The facility reported a census of 35 residents.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to maintain a clean, comfortable and homelike environment free of possible hazards. The facility reported a census of 32 residents.

Inspectors wroteBased on electronic health record (EHR) review, resident interviews, observations, policy review, and staff interviews the facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team composed of a resident and/or resident representative to allow developing the care plan and making decisions about his or her care and follow existing care plan interventions to 5 of 12 residents reviewed (Resident #2, #6, #24, #31 and #38). The facility reported a census of 32 residents.

Inspectors wroteBased on observation, record review, staff interview, Electronic Health Record (EHR) review, resident interviews and policy review the facility failed to provide quality nursing care by not completing assessments related to symptomatic positive influenza A diagnosis and symptomatic respiratory illness or having interventions in place related to the illness for 4 of 4 resident reviewed (Resident #8, #9, #28 and #38). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interviews, and policy review the facility failed to provide range of motion (ROM) services to a resident with limited ROM to prevent further decrease in range of motion or development of contractures for 1 of 14 residents reviewed (Resident #8). The facility reported a census of 32.

Inspectors wroteBased on Electronic Health Record (EHR) review, observation, resident interviews, and staff interviews the facility failed to provide adequate response from nursing staff to assure residents safety by not responding to call lights in a timely manner for 2 of 12 residents reviewed (Resident #6 and #16). The facility reported a census of 32 residents.

Inspectors wroteBased on facility document review, and staff interviews, the facility failed to employ a clinically qualified nutrition professional by not having a certified dietary manager (CDM). The facility reported a census of 32 residents.

Inspectors wroteBased on observations, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide appropriate infection prevention practices when providing care to a resident with an indwelling catheter and a nephrostomy tube that was on Enhanced Barrier Precautions (EBP), failed to appropriately wear Personal Protective Equipment (PPE) during the sorting of laundry and failed to provide appropriated infection control standards for an outbreak of influenza A at the facility for 5 of 5 resident reviewed (Resident #8, #9, #28, #31 and #38). The facility reported a census of 32 residents.

Inspectors wroteBased on observation, Electronic Health Record (EHR) review, policy review, resident interviews and staff interviews the facility failed to provide dignity and respect to 2 of 14 residents reviewed (Resident #8 and #12). The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 3 out of 5 sampled residents reviewed (Resident #5, #12, #20). The facility reported a census of 32 residents.

Inspectors wroteBased on resident interviews, staff interviews, documentation reviews and facility policy review, the facility failed to thoroughly investigate and report immediately alleged violations related to mistreatment of 1 resident (Resident #12) out of 8 reviewed. The facility reported a census of 32 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, staff interviews, and policy review the facility failed to obtain bed hold notifications for 1 of 3 residents (Resident #40) reviewed. The facility reported a census of 32 residents. Findings Include: Review of Resident #40's Minimum Data Set (MDS) dated [DATE] revealed diagnoses of anxiety disorder, bipolar disorder, adult failure to thrive, and chronic kidney disease. Review of Resident #40's EHR page titled, Progress Notes revealed an entry dated 12/31/25 documenting that Resident #40 was transferred to the emergency room for evaluation. Further review of the progress notes revealed an entry dated 1/5/26 that Resident #40 was re-admitted back to the facility from a hospital stay. Review of the EHR page titled, Clinical Census revealed that Resident #40 had been in the hospital from [DATE] until 1/5/26. [...]

Inspectors wroteBased on document review, staff interviews, and policy review, the facility failed to refer a resident with a negative Level I result for the Pre admission Screening and Resident Review (PASRR), who had an identified mental disorder, intellectual disability, or other related condition that was not addressed on PASRR completed prior to admission to the facility, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 resident (Resident #24) reviewed for PASRR requirements. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed (Residents #27, #42) requiring the use of oxygen. The facility reported a census of 32 residents.

Inspectors wroteBased on clinical record review, resident and staff interviews and facility policy review the facility failed to separate Resident #1 and Resident #3 to prevent a resident-to-resident altercation. The facility reported a census of 39 residents. Findings Include:1) According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: hypertensive heart disease, anemia, renal failure, psychotic disorder (other than schizophrenia), mild cognitive impairment, insomnia, and metabolic encephalopathy. A Care Plan Focus Area with an initiation date of 1/15/2025 documented Resident #1 had a history or potential for delusions due to her cognitive status. [...]

Inspectors wroteBased on clinical record review, facility investigative file review, resident and staff interviews, the facility failed to complete a thorough investigation after an altercation between Resident #1 and Resident #2 on 10/17/2025 and between Resident #1 and Resident #3 on 10/18/2025. The facility reported a census of 39 residents. Findings Include:1) According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: hypertensive heart disease, anemia, renal failure, psychotic disorder (other than schizophrenia), mild cognitive impairment, insomnia, and metabolic encephalopathy. [...]

Inspectors wroteBased on observations, clinical record review, facility document review and staff interviews the facility failed to provide proper supervision for 1 of 3 residents reviewed (Resident #1). On 10/17/2025 Resident #1 had an altercation with Resident #2 and was placed on one-to-one supervision. On 10/18/2025 staff failed to provide one-to-one supervision which resulted in an altercation involving Resident #1 and Resident #3. The facility reported a census of 39 residents. According to the Quarterly Minimum Data Set (MDS) assessment tool with a reference date of 9/13/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 3. A BIMS score of 3 suggested severe cognitive impairment. The MDS listed the following diagnosis for Resident #1: [...]

Inspectors wroteBased on clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to timely report an allegation of abuse between 2 residents reviewed (Resident #1 and #2) to the appropriate management staff member. The facility reported a census of 40 residents.

Inspectors wroteBased on record review, staff interviews and facility policy review the facility failed to update 2 of 3 resident's care plans (Resident #1 and Resident #2) after they were involved in a resident to resident altercation. The facility reported a census of 40 residents.

Inspectors wroteBased on resident interviews, staff interviews, clinical record review and staff file review, the facility failed to prevent accidents for 1 of 7 residents. Resident #36 slid from her wheelchair while being transported to an appointment in the facility van. The staff failed to ensure that the resident was stabilized by applying the shoulder strap of the seat belt. The facility reported a census of 47 residents.

Inspectors wroteBased on electronic medical record (EMR) review, resident interview, staff interviews, and policy review the facility failed to provide care and service to an individual with a feeding tube resulting in complication of enteral feeding and medication administration for 1 of 1 residents reviewed (Resident #1). The facility failed to identify the skills and abilities needed of the direct care staff when providing enteral medications to the resident resulting in 4 hospital visits including 3 overnight stays within 4 weeks. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to notify residents or resident representatives of room change decisions, or provide explanation for the changes for 4 of 4 residents reviewed (#19, #17, #8, #1). The facility reported a census of 47 residentsFindings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #19 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficit). She required partial assistance with dressing and hygiene and supervision only with walking and transferring. Resident #19 had daily wandering activity. The Care Plan for Resident #19, updated on 5/21/25, showed that she had the potential for eloping and staff were to remind her of the location of her room. [...]

Inspectors wroteBased on observations, interviews, Electronic Medical Record (EMR) reviews, and policy review the facility failed to notify the physician and resident representative when a change in medical condition and/or treatment occurred for 4 of 4 residents (Resident #1, Resident #14, Resident #19, Resident #18). The facility failed to notify a resident Power of Attorney (POA) of a positive Covid test, a resident's POA of a fall, a physician of oral and enteral feeding refusals with the resident having continued weight loss, and a resident's POA of a psychotropic medication change. The facility had a census of 47.

Inspectors wroteBased on employee file review, staff interviews and facility policy review the facility failed to complete additional research for 1 of 3 employees (Staff D CNA) when her background check indicated it required additional research. The facility reported a census of 47 residents.

Inspectors wroteBased on the previous Centers for Medicare and Medicaid Services (CMS) form 2567 review, staff interviews, and facility policy review the facility failed to ensure they provided a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 47 residents.

Inspectors wroteBased on record review, staff interviews, facility investigative file review, and facility policy review. The facility failed to ensure 2 of 3 residents (Resident #31 and #34) were free from abuse. The facility reported a census of 47 residents.

Inspectors wroteBased on record review, facility investigative file review, staff interviews and facility policy review the facility failed to report a reportable incident to the State Agency within 2 hours of the alleged incident. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review, and policy review the facility failed to review and revise the Care Plans for 2 of 36 residents reviewed (Resident #1 and Resident #34). The facility failed to revise the Interventions for a resident who received oral and enteral intake, and the Goals and Interventions for 2 residents for intimate relations. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, interviews, Electronic Medical Record (EMR) reviews, and policy review the facility failed to provide services meeting professional standards for 1 of 36 residents reviewed (Resident #1). The facility failed to enter orders on the Medication Administration Record (MAR) - Treatment Administration Record (TAR) for correct route, complete and document physician orders on the MAR - TAR, and follow physician orders for interventions required during oral intake. The facility had a census of 47.

Inspectors wroteBased on observation, staff and resident interviews and record review, the facility failed to ensure that residents received baths per preference for 1 of 3 residents reviewed. Resident #32 a paraplegia was unable to sit in the shower chair due to lack of trunk support. Staff were providing bed baths only. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, staff interviews, provider interview and policy review, the facility failed to ensure that residents received adequate and timely assessments and interventions for 2 of 12 residents reviewed (Residents #23 and #31). Staff failed to consistently monitor Resident #23 for side effects from psychotropic medications, and failed to complete neurological assessments after Resident #31 had an unwitnessed fall. The facility reported a census of 47 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that they monitored urine output for residents with urinary catheter and were at risk for urinary tract infections for 1 of 3 residents reviewed. (Resident #32.) The facility reported a census of 47 residents.

Inspectors wroteBased on electronic medical record (EMR) review, staff interviews, provider interview and policy review the facility failed to develop and implement interventions to stabilize or improve a resident's nutritional status before complications arose for 1 of 1 resident reviewed (Resident #1). The facility failed to monitor enteral and oral intake, respond to continuous weight loss over a 7 month period, and develop an integrated approach to the progression of enteral intake to oral intake. The facility reported a census of 47 residents.

Inspectors wroteBased on observations, Electronic Health Record (EHR) reviews, staff interviews, and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares for 3 of 3 residents (Resident #33, Resident #1, and Resident #32). The facility failed to maintain appropriate placement of catheter bag placement, utilize hand hygiene, appropriate glove use, and Enhanced Barrier Precautions (EBP). The facility reported a census of 47.

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to implement appropriate infection control practices to mitigate the spread of pathogens and diminish the risk of spreading SARS-CoV-2 (COVID-19) during an active outbreak. The facility reported a census of 48.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (April 1 - June 30) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 51 residents.

Inspectors wroteBased on the record review, resident interviews, staff interviews and policy review the facility failed to provide access to personal funds managed by the facility or manage personal funds deposited at the facility. The facility reported a census of 51 residents.

Inspectors wroteBased on observations, and staff interview, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. The facility reported a census of 51 residents.

Inspectors wroteBased on observations, and staff interviews, the facility failed to provide food served by a method to maintain a safe and appetizing temperature. The facility reported a census of 51.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to properly label stored food, failed to maintain sanitary practices by using the dedicated hand hygiene sink to fill a pitcher of water for resident use, and failed to ensure the appropriate amount of sanitizer solution was used to effectively sanitize food preparation surfaces. The facility reported a census of 51 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy reviews the facility failed to implement appropriate hand hygiene and infection control practices to mitigate the spread of pathogens during resident cares (Resident #48), medication administration and laundry delivery. The facility reported a census of 51.

Inspectors wroteBased on clinical record review, policy review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing the use of an anticoagulant, insulin or an indwelling catheter for 3 of 10 residents reviewed (Resident #25, #32 and #48). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record review, policy review and staff interviews the facility failed to provide a comprehensive care plan that included goals or interventions for enhanced barrier precautions (EBP) for a resident with a catheter and use of an anti-platelet for 2 of 10 residents reviewed (Resident #25 and #48). The facility reported a census of 51 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to protect residents from possible accidents and injuries for 2 of 17 residents (Resident #8, and #15) reviewed. The facility reported a census of 51 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide accurate and timely assessment and interventions. Staff failed to obtain a physician's order for home medications for 1 of 3 residents reviewed (Resident #3). Staff failed to adequately assess 1 of 3 residents reviewed for falls (Resident #4), and failed to contact the physician with high blood glucose levels for 2 of 2 residents reviewed (Resident #2, #9). The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, family interview, pharmacy staff interview, home health staff interview, facility staff interviews and facility policy review, the facility failed to ensure adequate discharge planning for 4 of 5 residents reviewed. Facility staff discharged Resident's #1, #3 and #6 without ensuring that they had the needed home medications. Staff discharged Resident #4 without advanced planning or arranging for the needed home health and therapy services. The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, family interviews, resident interview, staff interviews and facility policy review the facility failed to notify resident representatives after falls for 2 of 3 residents (Resident #6, and #4) reviewed. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, staff interview, clinical record review and facility policy review the facility failed to follow standard infection control practices related to proper hand hygiene for 1 of 3 residents reviewed. While providing incontinence cares for Resident #7, two Certified Nurse Aides (CNA) failed to change their gloves and perform hand hygiene after they had wiped the resident's legs and buttocks. The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, CDC guidelines, staff interviews, physician interview and facility policy review the facility failed to provide timely assessments and interventions for 3 of 13 residents reviewed (Resident #46, #8 and #37). Resident #46 had a urinary tract infection (UTI) and was on an antibiotic. Staff failed to conduct daily vital signs and did not contact the provider when his condition worsened. The resident went to the hospital in septic shock due to a kidney infection. Daily skilled nurse charting for Resident #8 and Resident #37 showed that staff used vital signs from previous days. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the Minimum Data Set (MDS) by not accurately assessing need for restraints and catheter for 4 of 4 residents reviewed (Resident #12, #29, #35, and 41). The facility reported a census of 45 residents.

Inspectors wroteBased on personnel document review, and staff interviews the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a qualified professional serve as the dietary manager. The facility reported a census of 45 residents.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to prepare, serve and distribute food in accordance with professional standards. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, facility documents, and staff interviews the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 1 of 3 residents (Resident #37) reviewed. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, and staff interviews the facility failed to refer 2 residents for the Pre-admission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 2 out of 5 residents (Resident #18 and #37) reviewed for PASRR requirements. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, staff interview, and facility policy review the facility failed to update the resident's care plan to accurately reflect the resident for 1 of 23 residents reviewed (Resident #29). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy review the facility failed to provide enteral tube feeding as appropriate per orders for 1 of 1 residents reviewed (Resident #45). The facility reported a census of 45 residents.

Inspectors wroteBased on observations, clinical record review, resident interview, and staff interviews the facility failed to change oxygen tubing for respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed (Resident #3) requiring the use of oxygen. The facility reported a census of 45 residents.

Inspectors wroteBased on clincial record review, facility policy review and staff interviews the facility failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment to 1 of 1 residents reviewed (Resident #31). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner. The facility reported a census of 45 residents.

Inspectors wroteBased on observation, staff interview, pharmacist interview and clinical record review the facility failed to ensure that residents did not have unnecessary medication prescribed for 1 of 5 reviews for narcotic medication use (Resident #30). The facility reported a census of 45 residents.

Inspectors wroteBased on observation, facility document review, staff interviews and clinical record review the facility failed to properly label and store resident medications according to regulations. In an observation on [DATE], it was discovered that three insulin pens did not have documentation of the date opened and 1 insulin pen was being used passed the recommended 28 days after opening. The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, staff interviews, and facility policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs for 1 of 10 residents reviewed (Resident #32) The facility reported a census of 45 residents.

Inspectors wroteBased on resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing and palatable temperature to 3 of 18 residents reviewed (Resident #1, #6, and #40) The facility reported a census of 45 residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide infection control measures to mitigate the spread of pathogens. An observation of the laundry room found that the wash machine chemical pumps were not working and none of the chemicals or soaps were getting into the wash. Observations during food service and during patient care revealed inadequate hand hygiene and lack of appropriate glove use. The facility reported a census of 45 residents