Oaks - Bethany Skilled Nursing, the

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility's policy titled Discharge Planning, the facility failed to ensure a safe and appropriate discharge for one of one sampled (R)(R113). The facility discharged R113 to an environment that was not safe, placing R113 at risk for psychosocial and physical harm. Findings Include:A review of the facility's policy titled, Discharge Planning last revised on 02/24/2025, documented, .The Discharge Summary provides the necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the patient/resident's plan for care after discharge, including but not limited to the following: Discharge Recapitulation of Stay Form. [...]

Inspectors wroteBased on observations, interviews, and review of the facility's policy titled, Oxygen Safety and Storage, it was determined that the facility failed to ensure there were no free standing oxygen cylinder tanks in one of 13 rooms (room [ROOM NUMBER]) on East Hall. This deficient practice has the potential to place residents at risk for accident or injury. Findings Include:A review of the facility policy titled Oxygen Safety and Storage revealed that it is the policy of [Facility Name] to assure that oxygen is administered and stored safely within the healthcare centers or outside storage areas. The Storage section further revealed: 1. Assure that oxygen tanks kept in storage rooms are either chained to the wall or installed on a stable, wheeled dolly or floor stand. [...]

Inspectors wroteBased on observation, staff interviews, and review of the facility policy titled Medication Storage in the Healthcare Centers, the facility failed to ensure a medication cart was locked or under direct supervision of authorized staff in an area accessible to residents for one of two wound care carts (West Unit). This deficient practice had the potential to allow resident access to unsecured medications. Findings Include:A review of the facilities policy titled, Medication Storage in Healthcare Centers, revealed that medications and biologicals are stored safely, securely, and properly following manufacturer recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, Certified Medication Assistants, and pharmacy personnel. [...]

Inspectors wroteBased on observations, staff interviews, and facility policy titled, Infection Control: Housekeeping Services, the facility failed to ensure residents living area was safe, clean, comfortable, and homelike for one room (room [ROOM NUMBER] West) and two of two shower rooms. Specifically, 4 [NAME] contained trash and a dark brown substance on floor, electrical cord and wall, while the shower rooms exhibited broken and missing tiles, black substance in the corner of the walls and floor and a build-up of soap scum on the shower walls. The deficient practice had the potential to affect patient comfort and safety.

Inspectors wroteBased on record review, staff interviews, and the facility policy titled Care Plans, the facility failed to create and/or implement a person-centered comprehensive care plan for two residents (R) (R2 and R8) from a sample of 11 residents. Specifically, R2 received the incorrect dosage of oxygen according to physician orders and R8 was not care planned for an assessed elopement risk. This deficient practice had the potential to place residents at risk of clinical complications, injury and diminished quality of life. Findings Include: Review of the facility's policy titled, Care Plans revised 7/27/2023, documented under Policy Statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan. and documented under admission Comprehensive Plan of Care: 4. [...]

Inspectors wroteBased on observations, interviews and facility policy titled Oxygen Administration, the facility failed to regulate and monitor oxygen liter flow rates according to physician orders for one resident (R)(R2) receiving continuous oxygen from a sample of 11 residents. This deficient practice had the potential to place resident R2 at increased risk of respiratory complications. Findings Include:A review of the facility policy titled Oxygen Administration revised 8/2/2023, documented under Policy Statement: It is the policy of PruittHealth Hospice and Healthcare Centers/Veteran Homes to provide Oxygen safely and accurately. and documented under Procedure: 4. Regulate liter flow to ordered/desired flow rate. [...]

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to ensure one out of 20 sampled Residents (R) (RA) was assessed to safely self-administer medications and that unauthorized and unsecured medications were not left at the bedside. This deficient practice placed RA at risk for unsafe medication use and allowed unsecured medications to be accessible to other residents and visitors.

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to ensure that the care plan intervention of a floor mat at bedside was implemented for one out of 20 sampled residents (R) (R8). The deficient practice placed R8 at risk for safety and injury.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to ensure that a floor mat was in place for one out of 20 sampled Residents (R) (R8), as a fall intervention. The deficient practice created a potential risk for safety and injury for the resident.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Labeling, dating, and Storage, Dietary Partner Hygiene and Dress Code, and Cleaning Schedule policy, the facility failed to label and date food items, wear hair coverings appropriately, and ensure fans in the kitchen are free of dust, dirt, and debris. This deficient practice had the potential to effect 89 out of 96 residents receiving an oral diet.

Inspectors wroteBased on record reviews, staff interviews, and review of the facility's policy Advance Directive, the facility failed to provide residents and/or their representatives written information regarding the right to accept or refuse medical or surgical treatment for six out of 42 sampled residents (R) (R53, R48, R88, R94, R55, and R76).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain a safe and homelike environment on three of seven halls (E3, E4, and [NAME] wing hall) and in the laundry room. Specifically, the shower room on E3 hall had broken wall tiles; Resident (R) (R19) on E4 hall privacy curtain was stained with a brown substance and motorized wheelchair had a build-up of brownish-black debris. Also, the laundry room had a ceiling vent that was coated with a dark greyish substance and the entrance to the laundry room had a large space preventing the door from closing securely. In addition, two sinks were clogged and holding water in shared bathrooms for room [ROOM NUMBER] and room [ROOM NUMBER] located on the [NAME] wing.

Inspectors wroteBased on observations, interviews and record review, the facility failed to promote, maintain, and protect residents' dignity for two of 42 sampled residents (R) (R11 and R67) who required assistance with feeding.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to assess four of 42 sampled residents (R) (R55, R37, R75, and R82) for the ability to self-administer medications (meds) prior to leaving meds at the bedside. The deficient practice had the potential to allow access to meds not prescribed by a physician for R55, R37, R75, and R82 and to other residents who may wander into the room.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to provide evidence that nutrition assessments were completed by the Registered Dietitian (RD) for one of 42 residents (R) (R88). Specifically, the facility failed to complete an admission nutrition assessment for R88.

Inspectors wroteBased on record review, resident interview, Family interview, staff interviews, and review of facility policy titled, Grievances: Healthcare Centers, the facility failed to ensure prompt efforts were made to resolve grievances related to shower preferences and personal property, for one of 14 residents (R) (R2).

Inspectors wroteBased on record review, and staff interviews, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure the resident assessment accurately reflected a resident's status for one of 14 residents (R) (R1). Specifically, the facility failed to ensure that R1 Minimum Data Set (MDS) was accurately coded to reflect residents documented wandering behavior and risk for elopement.

Inspectors wroteBased on record review, and Staff interviews, the facility failed to ensure that Activity of Daily Living (ADL) records were accurately documented for one of 14 Residents (R) (R2).

Inspectors wroteBased on observations, staff interviews, and review of facility policy titled, Infection Control-Housekeeping Services, the facility failed to maintain a clean, sanitary environment related to a heavy build-up of dust on the vent covers in nine (9) of 21 adjoining resident bathrooms in rooms (Rms) 3/5, 4/6, 8/10, and 7/9 on [NAME] (W) Hall, and in Rms 12, 14/16, 17/19, 18/20, and 21/22 on the Memory Unit. The deficient practice had the potential to affect the air quality for all the residents residing in resident care areas.