Oakridge Nursing Center

Inspectors wroteA past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective [DATE], related to the facility's failure to ensure:a. CPR was not stopped for a resident who was a full code, b. staff members could definitively identify a resident's code status, andc. effective cardiopulmonary resuscitation was provided by the use of a backboard and providing rescue breaths. A progress note, dated [DATE] at 4:07 a.m., showed a code had been called for Res #1 and CPR had been started. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. privacy was provided during care for one (#31) of four sampled residents reviewed for privacy; and b. protected health information was secured for three (#10, 170, and #173) of four sampled residents observed during medication pass. The administrator identified 65 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure restorative therapy was provided to residents with limited ROM for two (#33 and #51) of two sampled residents reviewed for restorative services. The regional survey consultant identified 27 residents who received restorative therapy resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent during the medication pass observation. The medication error rate was 15.38%. The administrator identified 65 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure: a. the required PPE was worn when providing care to a resident on transmission based precautions for one (#46) of four sampled residents who were reviewed for transmission based precautions; and b. infection control practices were maintained during medication administration observation. The administrator identified 65 residents resided in the facility. The infection preventionist identified 19 residents were on transmission based precautions.

Inspectors wroteBased on observation, record review, and interview, the facilty failed to ensure residents were assisted with eating in a dignified manner for one (#4) of four sampled residents observed during meal service. The administrator identified 65 residents in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a call light was within reach of a resident for one (#4) of 24 sampled residents observed for call lights in reach. The administrator identified 65 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents with limited range of motion received received restorative services to prevent further decrease in range of motion for one (#14) of two sampled residents reviewed for mobility. The DON identified 19 residents with impaired range of motion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain behavioral health services and develop a care plan related to the resident's behavioral health for one (#46) of two sampled residents reviewed for behavioral health service needs. The DON identified 48 residents who resided at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate code status was documented for a resident with DNR status for one (#13) of 16 sampled residents whose code status was reviewed. The administrator identified 48 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to notify the state authority of a new mental health diagnoses for two (#4 and #46) of three sampled residents reviewed for PASRRs. The administrator identified 48 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure baseline care plans were developed within 48 hours of admission for one (#32) of 17 sampled residents reviewed for care plans. The administrator identified 48 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify the physician of significant weight loss and implement interventions for one (#43) of two sampled residents reviewed for nutrition. The administrator identified 48 residents resided in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to change oxygen tubing according to physician orders for one (#13) of one resident sampled for respiratory care. The DON identified 11 residents received oxygen therapy.

Inspectors wroteBased on record review and interview, the facility failed to provide residents with an advance directive acknowledgement for five (#14, 19, 43, 52, and #258) of five residents reviewed. The Census and Conditions of Residents form documented 50 residents resided in the facility.

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders related to diabetic care for three (#43, 52 and #14) of three residents reviewed for diabetic care. The DON identified 18 residents with a diagnosis of diabetes.

Inspectors wroteBased on record review, observation, and interview, the facility failed to obtain physicians orders for urinary catheter care for two (#33 and #51) of two residents reviewed for urinary catheters. The Resident Census and Conditions of Residents documented four residents had indwelling or external catheters.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide pressure relieving techniques on one (#6) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents documented four residents with pressure ulcers.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored in a secure manner and under the direct observation of staff during medication administration. The administrator reported the facility utilized two medication carts.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (CNA #1) of 65 staff members had documentation of being fully vaccinated, exempted or an temporary delay. The Covid-19 Staff Vaccination Matrix for Providers documented 65 employees were employed by the facility.