Oakwood Health Services

Inspectors wroteBased on interview and record review, the facility did not ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 7 of 7 residents reviewed (R7, R11, R39, R41, R44, R70, and R74). There was no documentation of non-pharmacological interventions for pain for R7, R11, R39, R41, R44, R70, and R74. Facility ran out of pain medications for R44.

Inspectors wroteBased on observations, interviews, and record review, the facility did not determine safe self-administration of medications for 1 out of 17 residents (R) reviewed (R39). Surveyor observed R39 to have a cup of medications on the bedside table sitting in front of her while she was sleeping in her chair. R39 did not have an assessment for self-administration of medications, and R39 did not have a physician's order for self-administration. This is evidenced by: The facility's policy titled, Medication Administration, Section 7.3, Self-Administration by Resident dated 1/26, states in part, . Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the medications are appropriate and safe for self-administration. The facility's policy titled, Medication Administration, Section 7.1, General Guidelines dated 1/26, states in part, 13. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 resident (R39) of 5 medication administration observations was fully informed of but not limited to; resident rights and required medication information with options as requested by R39 prior to administering R39's medications during medication administration. Registered Nurse (RN) N did not provide information as requested by R39 before administering questionable medications that R39 had concern for.

Inspectors wroteBased on record review and interview, the facility did not ensure employees were screened for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was not obtained before employee started working at facility. (LPN M).

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure that a resident receives appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 3 reviewed. (R20)-R20 has a suprapubic catheter, and it was not kept below the bladder level. The facility policy titled, Catheter Care, dated 03/15/23, indicates drainage bags are to be located below the level of the bladder to discourage backflow of urine. There is no mention of proper tubing placement. R20 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, retention of urine, dysfunction of bladder, cystostomy, and history of MRSA. R20's Minimum Data Set (MDS), dated [DATE], indicated that R20 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating that R20 had moderately impaired cognition. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure ongoing assessment of the resident's condition and monitoring for complications before dialysis treatments for 2 of 2 residents reviewed (R1, R6). R1 and R6 did not have pre-dialysis weights performed. Previous dialysis day's weights utilized for majority of assessments.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure drugs and biologicals were labeled with an open date/expiration date in accordance with currently accepted professional principles for 1 of 1 resident (R) (R11). Facility did not have an open/expiration date label on R11's opened bottle of Roxanol.

Inspectors wroteBased on observations, interviews, and record review, the facility did not provide special eating equipment and utensils for residents who need them when consuming meals for 1 of 17 residents reviewed. (R14)R14 requires the use of a divided plate, built up utensils, and a nosey cup. R14 was not provided with built up utensils or the nosey cup during lunch. R14 was admitted on [DATE] with diagnoses that include dementia, stroke, abnormal posture, dysphagia, and diabetes. R14's most recent Brief Interview of Mental Status (BIMS) score was 0 of 15 which indicates R14 had severe cognitive impairment. R14's care plan with a revision date of 01/27/26 notes R14 is at risk for nutritional status due to diabetes and dementia. Interventions include set up assistance and to encourage to use divided plates, nosey cup, built-up utensils and clothing protector. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish and 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 for 1 out of 3 residents (R) observed for wound care (R70) Staff did not change gloves or perform hand hygiene during observation of wound care. R70's wound suction tubing was unplugged, and the open end of suction vacuum tubing was touching the floor. Staff did not clean or disinfect the tubing end prior to reconnecting to clean wound suction dressing.

Inspectors wroteBased on record review, observation and interview, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not ensure staff were applying the correct size Hoyer (mechanical full body lift) sling to prevent accidents for 1 of 10 residents (R) reviewed. (R3). Certified Nursing Assistants (CNA) used a size large instead of the care planned size medium Hoyer sling for R3. This occurred after nursing staff received education and skill checks within the last month.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from mental abuse by staff. This affected 1 of 3 residents (R1) reviewed for mental abuse. Staff held R1 down and forced R1 to be catherized against her wishes. As a result, R1 experienced severe trauma and fear, stating she did not feel safe in the facility and requested to be removed from the facility. The facility's failure to ensure R1 was free from abuse created a finding of immediate jeopardy that began on 2/01/25. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) G were notified of the immediate jeopardy on 2/12/25 at 3:32 PM. The immediate jeopardy was removed 02/01/25 and corrected on 02/03/25. Based on this determination, this citation is being cited as past noncompliance. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. The facility did not have an adequate surveillance in place for tracking and monitoring infection and communicable disease for staff and residents. The facility did not ensure proper fitting N95 mask for staff with facial hair of a full beard. Facility staff did not dispose of contaminated Personal Protective Equipment (PPE) before exiting COVID positive rooms. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not develop a person-centered care plan for 1 of 12 sampled residents (R35). The facility did not identify R35's individual choices and daily routines, which had the potential to negatively impact R35's quality of care and quality of life. During the comprehensive assessment, R35 indicated a desire to smoke. R35's comprehensive care plan did not address R35's preferences for smoking, which resulted in R35 complaining of not being able to smoke, feeling frustrated with staff, and expressing negative behaviors.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents (R28) reviewed. The facility did not implement R28's Range of Motion (ROM) developed plan of care. This is evidenced by: R28 was admitted to the facility on [DATE]. R28's diagnoses, that include but are not limited to, are hemiplegia affecting right dominant side, rheumatoid arthritis, and right shoulder contracture. R28's Minimum Data Set (MDS) annual assessment dated [DATE] and quarterly assessment dated [DATE] were reviewed. R28's Brief Interview of Mental Status (BIMS) score is 15 out of 15, indicating cognition is intact. R28 requires the assist of 1 staff member with transfers and bed mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not use a gait belt to promote safe transfer for 1 of 2 residents. (R9) This is evidenced by: Surveyor reviewed the facility's policy titled, NSG-Safe Resident Handling and Transfers. Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience .in accordance with standards and guidelines. The following numbers of sections relate to the numbered section in the policy. 1. The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other facts as well, such as weight and cognitive status. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 4 sampled residents (R)1 and R3. On admission 5/20/24, staff identified R1 had a suspected deep tissue injury (DTI) from the coccyx to the peri area. Physician, Director of Nursing, or wound nurse were not notified of this suspected DTI. No care plan or interventions were put in place for the pressure injury. Pressure injury assessments were not completed after the identification of the DTI on 5/20/24. As a result, R1 developed an unstageable pressure injury and sepsis. R1 required hospitalization and surgical debridement of the PI. The PI was staged as a stage 4 pressure injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify resident's physician about a change in condition for 1 of 4 sampled residents (R)1. The facility did not inform physician about a deep tissue injury and change in vital signs for R1.

Inspectors wroteBased on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 51 residents in the facility. The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for scabies. Multiple nursing staff members worked when they had scabies and were being treated, then worked on multiple other resident units, thus exposing other residents to scabies. The facility did not have a tracking program in place for the early detection of exposed residents on these other units. This is evidenced by: [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure 1 of 3 residents (R2) were provided care and services to promote regular bowel movements (BM) that are in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs.

Inspectors wroteBased on interviews and record reviews, the facility did not calculate 1 of 3 sampled residents' (R2) fluid intakes who are at high risk for dehydration, in order to determine if meeting a sufficient fluid intake to maintain or improve proper hydration and health. This is evidenced by: The facility policy, entitled Hydration, dated 07/26/22 states, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Sufficient fluid means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake: and maintain health. The amount needed is specific for each resident and fluctuates as the resident's condition fluctuates (i.e., increase fluids if resident has fever or diarrhea). [...]

Inspectors wroteBased on observations and interviews, the facility did not ensure food is not stored and or prepared under sanitary conditions. This has the potential to affect all 57 residents. Thermometer not cleaned before taking temperature of food. Gloved hands used to touch meat that has touched other surfaces. Gloves used to prepare food not changed between tasks. Cake cooled in front of an open window.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff observed not wearing proper Personal Protective Equipment (PPE) in a Resident (R) room on contact precautions for 1 of 1 resident on transmission based precautions. (R36) Staff did not offer hand hygiene in small dining room for breakfast served to 3 out of 8 sampled residents (R). (R14, R252, R102) Staff did not perform appropriate hygiene after allowing a resident to kiss and lick their arm. Staff did not perform hand hygiene during room tray delivery and between patient care areas for 6 out of 7 sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 residents (R26) reviewed for skin concerns. R26 had a left hip surgery on 6/22/23 requiring daily dressing changes along with comprehensive assessments after the removal of the wound vac on 6/27/23. The facility did not complete the ordered daily dressing changes and did not complete weekly comprehensive assessments of the incision site. This was evidenced by: The facility policy, entitled Pressure Injuries and Non-Pressure Injuries, dated 7/20/22, states: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 residents (R26). R26, who is her own person, left the facility without letting staff know she was leaving. The facility was not aware R26 was missing until they received a call from R26's daughter. No interventions were put in place after the incident that would bring awareness of this behavior and prevent future unsafe behaviors. This was evidenced by: The facility policy, entitled Elopement/Unsafe Wandering, dated 8/09/22, states: [...]