Oaklawn Health Care, LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist identified and reported a medication irregularity during the required monthly drug regimen review for 1 of 1 residents (R1), when an unauthorized Haloperidol order remained active despite the resident's diagnoses of epilepsy and Parkinsonism. This failure resulted in the medication remaining on the resident's medication regimen from March through June 2026 without identification during the required monthly pharmacist reviews. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 residents (R1) was free from a significant medication error when Haloperidol was entered into the facility's integrated electronic medication ordering system and administered to R1 from 3/13/26 through 6/9/26 without a valid and verified physician order.

Inspectors wroteBased on observation, interview, and record review the facility failed to remove discontinued medications from the active medication storage for 2 of 2 residents (R3, R4) creating the potential for inadvertent medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe, sanitary and comfortable environment for 1 of 1 residents (R2) whose room was unkept and had resident care items placed on the floor. In addition, the facility failed to perform daily cleaning in the kitchen which had the potential to affect 54/56 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nutrient and/or calorie substantive snacks were offered after the evening meal and before bedtime, for 2 of 2 residents (R2, R42) when there had been more than a 14-hour lapse between the dinner meal and breakfast the following day. This had the potential to affect 54 of 56 residents who ate meals at the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure appropriate follow-up of urine culture and sensitivity results and failed to ensure antibiotic therapy was reviewed for effectiveness for 1 of 1 resident (R32) reviewed for antibiotic use. In addition, the facility failed to ensure a nutritious snack was offered for the management of low blood sugar and failed to inform the dietician of concerns with blood sugar levels for 1 of 1 resident (R50) reviewed for food.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess and implement interventions to maintain and/or prevent loss of range of motion (ROM) for 1 of 1 resident (R21) reviewed for ROM.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a comprehensive care plan for diabetic management that included goals and individualized interventions was developed or 1 of 3 residents (R2) reviewed for care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented proper peri care techniques, including use of Enhanced Barrier Precautions (EBP), appropriate glove changes, and hand hygiene, to prevent or mitigate the risk of urinary tract infections for 2 of 2 residents (R2, R4) reviewed for peri care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards of practice were followed during administration of eye drops for 3 of 3 residents (R12, R15, R106) observed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide shaving for 1 of 1 resident (R45) who was dependent on staff for assistance with grooming and personal hygiene.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe smoking area, extinguishing of cigarettes in designated container, and monitoring of designated smoking area for 2 of 2 residents (R20 and R18) reviewed for smoking.

Inspectors wroteBased on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the culinary services director (CSD)-B was certified to oversee nutrition and food services. This had potential to affect all 45 residents who received meals from the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 2 of 2 refrigerator/freezers designated for resident food brought into the facility, were monitored to ensure food items were properly stored, labeled, and dated to reduce the risk of contamination and/or foodborne illness. This had the potential to affect any resident who utilized the refrigerator/freezers. In addition, the facility failed to ensure a culinary services cook (CSC)-A wore covering over beard to prevent hair from contaminating food, surfaces and utensils. This had the potential to affect all 45 residents who ate food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure personal protective equipment (PPE) was donned (put on) and doffed (removed) appropriately for 1 of 1 resident (R206) who had been in transmission-based precautions (TBP) due to testing positive for Covid-19.

Inspectors wroteBased on interview and document review, the facility failed to ensure the pneumococcal (PCV20) vaccine was offered or administered as recommended by the Centers for Disease Control (CDC) for 1 of 5 residents (R157) reviewed for immunizations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to coordinate an appointment with a dental provider for 1 of 1 resident (R8) who requested a dental appointment for dentures.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure safe mechanical lift transfers were completed along with following manufacturer guidelines for Med Care lift that expired, and ensuring correct sling/harness sizes for 7 of 7 residents (R4, R5, R6, R7, R8, R9, R10) who utilized this mechanical lifts. This resulted in an immediate jeopardy (IJ) for R1 who fell from the Med Care sit to stand lift resulting a fractured right femur (thigh bone) on 10/9/23. This had the likelihood for serious harm, impairment or death for R4, R5, R6, R7, R8, R9 and R10 who continued to use this Med Care sit to stand lift. In addition, the facility failed to ensure a preventive lift maintenance program was followed and staff had knowledge of using the correct size harness/sling size for their mechanical lifts. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure timely reporting to the State Agency (SA) was completed when 1 of 1 resident (R1) fell from a mechanical lift as a result of NA not following the care plan which resulted in a right femur fracture.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper catheter cleaning and storage was provided to prevent possible urinary tract infections (UTIs) for 4 of 6 residents (R1, R3, R5 and R15) observed for catheter use.