Oakridge Gardens Nur Ctr, Inc

Inspectors wroteBased on staff interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who was a certified dietary manager, a certified food service manager, had a national certification for food service management and safety from a national certifying body, or who had an associates or higher level degree in food service management or hospitality. This practice had the potential to affect all 66 residents residing in the facility. Dietary Manager (DM)-F was not enrolled in an approved Dietary Manager training course.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications for 3 residents (R) (R270, R62, and R57) in 3 of 6 medication carts were labeled and/or dated appropriately and that expired medical supplies were removed from storage. In addition, the facility did not ensure expired supplies were removed from storage in 2 of 4 medication storage areas. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. Medication carts contained open, unlabeled and undated inhalers, eye drops, and nasal sprays and expired medical supplies. Medication storage areas contained expired items.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. The facility did not ensure food was dated/stored in a manner to ensure food safety.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 66 residents residing in the facility. Staff line lists did not contain last symptom dates or times and/or return to work dates for 14 staff. In addition, the facility allowed 7 staff with gastrointestinal (GI) illness symptoms to return to work earlier than recommended per the facility's policy and the Centers for Disease Control and Prevention (CDC) guidelines. The facility also allowed 1 staff who tested positive for influenza to return to work earlier than recommended per the facility's policy. R172 was on contact precautions. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 residents (R) (R50 and R57) of 23 sampled residents had the appropriate signatures on their Emergency Care Do Not Resuscitate Order (DNR) forms (Department of Health Services (DHS) Division of Public Health F-44763) thus rendering the DNR orders invalid. R50 had an activated Power of Attorney for Healthcare (POAHC). R50's DNR form was not signed by R50 or R50's POAHC. R57's DNR form was not signed by R57 or R57's POAHC.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the required Minimum Data Set (MDS) assessment data was transmitted timely for 3 residents (R) (R16, R175, and R174) of 3 sampled residents. R16 and R175s' Discharge MDS assessments were not completed or submitted. R174's Discharge MDS assessment was not submitted.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not follow the plan of care during a transfer for 1 resident (R) (R45) of 2 sampled residents. R45 had a history of falls. R45's plan of care contained an intervention to use a gait belt and a 2-wheeled walker during transfers. On 5/12/25, staff transferred R45 without a gait belt or 2-wheeled walker.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the medication error rate was below 5%. During medication administration, Surveyor observed 4 errors out of 27 opportunities which resulted in an error rate of 14.81%. This affected 3 residents (R) (R36, R172, and R33) of 5 residents observed during medication administration Staff did not ensure intravenous (IV) medications were administered within the scheduled time frame for R36 and R172. Staff did not ensure R33's blood pressure was within the ordered parameters prior to administering medication.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an allegation of abuse for 2 residents (R) (R2 and R1) of 2 sampled residents. R2 reported an allegation of physical abuse on 1/19/25 that involved Certified Nursing Assistant (CNA)-E. The facility did not ensure CNA-E was removed from or supervised during resident care pending the results of the investigation. R1 reported to a nurse on 11/29/24 that R1 was recently raped by an unknown male staff. The facility did not thoroughly investigate the allegation of sexual abuse.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect 73 of 73 residents residing in the facility. Staff did not date items with open dates and received dates. Staff did not ensure food was stored in a sanitary manner. Staff did not wash hands when moving from dirty to clean activities. Staff did not wait two minutes to take microwave reheated food temperatures to ensure food was heated evenly. In addition, staff did not ensure microwaved foods reached the food safety temperature prior to serving.

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 Resident (R) (R50) of 2 residents. R50 was observed laying across another resident in their bed without clothes on. The potential allegation of abuse was not reported to the State Agency (SA) or local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate a potential allegation of abuse for 1 Resident (R) (R50) of 2 residents. R50 was observed laying across another resident in their bed without clothes on. Facility administration was not aware the incident occurred and a thorough investigation was not completed.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure consistent communication for 1 Resident (R) (R24) of 1 resident who received dialysis services. The facility did not provide R24 with a dialysis communication binder prior to routine dialysis appointments and did not have evidence of communication between the facility and the dialysis center on R24's dialysis days.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R34) of 3 residents with a diagnosis of dementia received the appropriate care and services to attain or maintain their highest practicable well being. R34 had a diagnosis of dementia and exhibited physically and verbally aggressive behavior. The facility did not revise R34's plan of care in an attempt to provide effective dementia treatment and behavioral interventions to enhance R34's quality of life.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 73 residents residing in the facility. IP-J did not complete specialized training for infection prevention and control.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 Resident (R) (R25) of 7 residents reviewed for Preadmission Screen and Resident Review (PASARR) had an updated Level I screen or a Level II referral completed when R25 was diagnosed with major depressive disorder and prescribed psychotropic medication (medication that affects a person's mental state). On 6/10/22, R25's provider prescribed fluoxetine (an antidepressant medication). On 9/8/22, R25's provider also prescribed lorazepam (an antianxiety medication). On 10/12/22, a diagnosis of major depressive disorder was added to R25's diagnoses list. A PASARR Level I screen and a Level II referral were not completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R12, R44 and R7) of 6 residents reviewed for nutrition and weight loss received the necessary care and services to meet nutritional goals and prevent continued weight loss. R44 had a 15 pound or 11.56% unintended weight loss within three months. The facility did not update the provider regarding R44's unintended weight loss. In addition, the dietician's recommendations for a dietary supplement, appetite stimulant and to weigh R44 were not reviewed or implemented by the facility. R12 had a 9 pound or 5.49% unintended weight loss within one week. The facility did not monitor R12's variation of weight or update the provider following the unintended weight loss. In addition, the dietician's recommendation for a dietary supplement was not reviewed or implemented by the facility. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 2 Residents (R) (R54 and R163) of 8 sampled residents reviewed for influenza vaccination were offered the vaccine. In addition, the facility did not ensure 2 Residents (R35 and R163) of 8 sampled residents reviewed for vaccinations were offered the Prevnar (PCV) 13 vaccine as indicated. R54 was admitted to the facility on [DATE] and was not offered the influenza vaccine. R35 was admitted to the facility on [DATE] and was not offered the PCV13 vaccine. R163 was admitted to the facility on [DATE] and was not offered the influenza or PCV13 vaccines.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R54, R163, and R260) of 8 residents reviewed for vaccinations were offered or received the COVID-19 vaccine. R54, R163, and R260's medical records did not include documentation that indicated the residents received or declined the COVID-19 vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R) (R58, R32 and R18) of 15 residents reviewed for hospitalization received the proper notice to include date of transfer, reason for transfer, location of transfer, appeal rights and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the State Long-Term Care Ombudsman of hospital transfers for 14 Residents (R58, R10, R11, R25, R34, R47, R48, R173, R174, R175, R176, R177, R32 and R18) of 15 residents reviewed for hospitalization. R58 was transferred to the hospital on [DATE]. The facility did not did not inform R58's representative in writing or the Ombudsman of the transfer. R10 was transferred to the hospital on [DATE]. The facility did not inform the Ombudsman of the transfer. R11 was transferred to the hospital on [DATE]. [...]