Oakridge of Plattsburg

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and home like environment for three sampled residents (Resident #4, #14 and #27), when the facility did not ensure window curtains were in good repair and air conditioning units were clean in resident rooms and failed to ensure bathrooms in resident rooms were in good repair. This affected three of 14 sampled residents (Resident #4, #14 and #27). The facility census was 55. The facility did not provide the requested policy on environment.1. Observation of the Resident #4's room on 03/04/2026 at 02:31 P.M., showed:-The vents of air conditioner were covered in dust and dirt;-The air conditioner was on and blowing cold are and dust into the room;-The bathroom door is stuck shut and was hard to open;-The bathroom door had a strip of missing paint on the top of the door;-The window curtains were torn and frayed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate Activities of Daily Living (ADL) cares for dependent residents when the facility allowed a resident to remain in his/her wheelchair for over four hours without repositioning the resident, toileting the resident, providing oral care after meals or offering the resident a drink; affecting one resident (Resident #29). And when the facility failed to ensure proper perineal care was provided to one resident when a staff member used a disposable cleansing wipe multiple times to clean bowel movement off of a resident (Resident #25). The facility census was 54. Review of the facility's ADL Policy dated 01/31/2024, showed that the facility is to assist the resident in achieving maximum function. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with an indwelling catheter received the appropriate care and services to prevent urinary tract infections to the extent possible when the facility failed to ensure proper catheter care was provided for two (Resident #25 and Resident #8) of the 14 sampled residents. The facility census was 55. Review of the facilities Catheter, Emptying Urinary Drainage Bag policy, dated 1/31/24, showed:- Place a paper towel beneath the drainage bag;- Position the measuring container under the drainage bag;- Remove the drainage tube from it's holder;- Open the drainage and let urine flow into the measuring container;- After the drainage bag has emptied, close the drain;- Wipe the drain with an alcohol sponge or swab;- Replace the drain back into it's holder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was less than five percent for two sampled residents (Resident #29 and Resident #30) out of 26 opportunities, when staff administered a rectal suppository without lubricant, withheld a prescribed medication, and additionally when staff documented a medication was administered when it was withheld; causing a 12% medication error rate. The facility census was 54. Review of the facility's Medication Administration Policy dated April 2019, showed:-Medications are administered in a safe and timely manner;-Medications are administered in accordance with prescriber orders;-If a dosage is believed to be inappropriate or excessive, the person administering the medication will contact the prescriber or facility's medical director to discuss concerns. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates, for 10 sampled residents (Residents #1, #3, #6, #8, #29, #33, #48, #52, #53, and #56) when the facility had six opened multi-use medications that were not labeled with the open date, six opened multi-use medications with open date over 28 days prior to observation date and one large, opened, undated syringe of topical medication without a medication or resident label. The facility census was 54. Review of the facility's Medication Storage policy dated 02/01/2024, showed:-No discontinued, outdated or deteriorated drugs may be retained for use;-All outdated or discontinued drugs must be returned to the issuing Pharmacy to be destroyed in accordance with established guidelines; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when the facility failed to ensure staff wore enhanced barrier precautions (EBP surgical gown and gloves) while providing direct care to residents with wounds and/or indwelling medical devices for two residents, (Resident #9 and Resident #25) and when the staff failed to use an alcohol wipe to clean a insulin bottle and allow an the injection site to dry for (Resident #3), and additionally when the facility failed to ensure all staff members had tuberculin skin testing (TB), a test performed to determine if a person has been exposed to tuberculosis, performed before beginning employment this had the [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles by not maintaining an accurate accounting of all monies held in the resident trust fund account and by not reconciling each month. The facility managed funds for 5 residents. The facility census was 54. Review of facility policy, Resident Trust Fund Account Management, revised 3/5/26, showed: - The facility will maintain accurate accounting, protect resident funds from misappropriation, and ensure residents maintain control over their personal finances.- Resident funds will be maintained separate from facility operating funds. The total balance of resident ledgers must equal the resident trust account bank balance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and a safe dining environment for one resident (Resident #1) who sustained burns to the fingers on the right hand, when left un-attended during meal service and was witnessed by Resident #2. This affected one out of four residents sampled. The facility census was 52. On 10/14/25, the Administrator was notified of the past noncompliance which occurred on 10/7/25. On 10/7/25, facility administration was notified of the incident, an investigation immediately began, and corrective action were implemented to include a new policy for meal service for residents who require assistance, and staff training regarding meal service that included staff education that supervision and assistance must be provided to residents when served. The non-compliance was corrected 10/7/25. [...]

Inspectors wroteBased on observation and interviews the facility failed to provide a comfortable and homelike environment for all residents when they did not ensure cobwebs were cleaned from the dining room as well as the common area near the facility entrance, and failed to match the paint when repairing drywall in the dining room, or to ensure ceiling trim in the dining room was secure around attic access in the dining room. Additionally, the facility failed to maintain resident safety when they did not ensure a handrail was secure, and failed to provide a homelike environment when they did not fix or replace dining room chairs that are had tearing in the fabric. The facility census was 55. The facility did not provide a policy for regarding maintaining the facility. 1. Observation of the diningroom on 11/18/24 at 10:59 showed: -Dining room chairs vinyl was peeling off and fabric was torn. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, complete morning hygiene cares, offer fluids, or toilet dependent residents. These failures affected three of the 14 sampled residents (Residents #4, #34and #44). The facility census was 55. Review of the facility's policy for peri care - female, revised 2/1/24, showed, in part: - Purpose: To provide comfort for the resident and to prevent infection. - (7.) Expose peri area, separate inner labia and gently wash from front to back. - (8.) With new wipe, gently open all inner skin folds and wash inner area from front to back. - (9.) With new wet wipe, wash the outer skin fold from front to back. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents' safety and independence by pushing residents in their wheelchairs who are able to propel themselves for four of the fourteen sampled residents (residents #17, #10, #39, and #19). The facility census was 55. Review of the Accidents and Incidents policy did not show any details regarding footrest safety. 1. Review of Resident #17's Quarterly MDS (minimum data set), a federally mandated assessment tool completed by facility staff, dated, 9/19/24, showed: -Resident has severely impaired cognition. -Resident is able to wheel themselves in a wheelchair for 150 feet without assistance from helper. -Diagnoses included traumatic brain dysfunction, high blood pressure, anxiety, and depression. Observation on 11/18/24 at 11:29 A.M. showed: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation, failed to review the risk and benefits with the resident or the resident's representative (Resident #5, #45) , failed to obtain informed consent prior to installation (Resident #5 and #45), failed to ensure the bed's dimensions were appropriate for the resident's size and weight (Resident #5 and #45), failed to obtain a physician's order prior to installation of side rails (Resident #5), and failed to complete quarterly safety assessments for residents (Resident #5, #45), and failed to care plan side rails (Resident #5). This included four of 14 residents sampled (Residents #5, #45, #17, and #42). The facility census was 55. Review of facility policy, bed assist bar usage, revised 4/24/24, showed: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent (%). Staff made 6 medication errors out of 31 opportunities for error, which resulted in an error rate of 19.35%. This affected 4 of the 14 sampled residents, (Residents #5, #29, #49, and #50). The facility census was 55. Review of the facility's policy for preparation and administration of oral medications, revised 2/1/24 showed, in part: To ensure the resident receives prescribed medications as ordered by Doctor utilizing the most current nursing practice. Review and verify medication administration records/medication cards with Doctor's order according to facility policy. Check medication record/card and remove the container of medication from the bin. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to utilize proper thawing techniques, failed to ensure garbage cans were kept covered when not in use, failed to properly sanitize all food preparation surfaces in kitchen, failed to store dishes in an inverted position, failed to implement proper hand washing techniques, and failed to ensure proper storage and labeling of foods. The facility census was 55. 1. Review of facility policy, waste disposal, dated April 2011, showed: -All waste must be placed in lined garbage and trash cans and kept covered when not in use. Observation on 11/18/24 9:07 A.M., showed there was no lids on two large trash cans, one in dishwashing area and one towards back of kitchen. Observation on 11/20/24 at 9:21 A.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control practices to reduce the development and spread of infections for three of the 14 sampled residents (Resident #18, #24, and #53), and failed to ensure the urinary catheter drainage bag for Resident #53 did not touch contaminated surfaces. The facility additionally failed to place residents with wounds (Resident #18 and Resident #24) and with urinary catheters (Resident #18 and #53) on enhanced barrier precautions (EBP). The facility census was 55. Review of the facility's Enhanced Barrier Precautions policy, dated August 2022, showed: - EPBs are utilized to prevent the spread multi drug resistant organisms (MDRO) to residents; - EPBs employ targeted gown and glove use during high resident care activities when contact precautions do not otherwise apply; [...]

Inspectors wroteBased on record review and interview, the facility failed to keep residents' money separated from the facility's operating account. This effected eight additionally sampled residents (Resident #37, #156, #157, #158, #159, #160, #161, and #162). The facility census was 110. Review of the facility policy titled Guidelines for Maintaining the Resident Trust Fund Account, dated [DATE], showed the following: - This facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf. - A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf; [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to cover any loss or theft to residents' money held in the facility's Resident Trust Fund (RTF) account which had the potential to affect all eight residents who had money held in their RTF account. The facility census was 53. The facility did not have a policy for surety bonds. 1. Review of the facility's RTF documents showed there were currently eight residents with open RTF accounts in the facility. Review of the facility's approved surety bond, approved on 6/3/1996, showed an approved amount of $10,000.00. Review of the RTF worksheet on 1/12/23, showed: - The average monthly balance for the facility's interest bearing account of $11,923.42; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer, in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure dependent residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care, which affected three of 14 sampled residents (Residents #28, #29, and #36). The facility census was 53. Review of the perineal care of the female resident policy, dated 2/7/23, showed: - The purpose of perineal care was to provide comfort for the resident and prevent an infection. - The staff was supposed to separate the inner perineal folds and wipe from front to back with a clean wipe. - Wipe from front to back the outer skin folds with a clean wipe. - With a new wet wipe clean the inner thighs. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM or to prevent further decrease in ROM. This affected four (Resident #2, #7, #8, and #19) of 14 sampled residents. The facility census was 53. Review of the restorative nursing policy, dated 2/7/23, showed: - The purpose policy was to identify residents that would benefit from restorative nursing services and to maintain the current level of independence. - The therapist will meet with the restorative aide once the resident's skilled therapy has been completed. - The charge nurse will be responsible to obtain an order for restorative services. - The restorative aide will be responsible for documentation of the restorative services provided. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated residents in a manner that maintained their dignity when staff stood to assist residents to eat which affected three of 14 sampled residents (Resident #42, #44, and #52). The facility census was 53. Review of the facility's undated policy for assistive dining for the dependent resident showed, in part: - To assist any resident that cannot feed themselves and maintain adequate nutrition as able; - Sit down while feeding the resident. 1. Review of Resident #42's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 1/25/23, showed: - Cognitive skills intact; - Supervision with set up and eating; [...]