Oakwood Rehab and Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that individual food preferences/food choices were assessed, and menus were provided to accommodate those preferences for 6 of 6 residents (R1-R3 and R5-R7) reviewed for food preferences. This failure affects all 102 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable homelike environment due to a lack of supplies needed for basic daily living. This failure affects all 99 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for a resident (R2) to prevent a fall. This resulted in R2 obtaining a fracture to her right clavicle. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received provisions of care and services required when a licensed nurse left the assigned unit resulting in lack of consistent nursing supervision and nursing care. This failure directly affected 3 residents (R2, R3 and R7.)

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve portion sizes as shown on the menu for the lunch meal. This applies to 7 of 13 residents (R2, R4, R5, R10-R13) reviewed for meal prep and service in the sample of 13.

Inspectors wroteBased on observations, interviews and record review, the facility failed to serve food at a palatable temperature acceptable to residents. This applies to 8 of 13 residents (R2, R4, R9, R5, R10-R13) reviewed for poor preparation/cold foods in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident rooms were cleaned routinely for 5 of 6 residents (R1, R6, R11, R12 and R13) reviewed for clean, comfortable and homelike in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff wore personal protective equipment when caring for residents who are positive for COVID-19 to prevent to spread of infection for 6 of 9 residents (R14-R18 and R20) reviewed for infection control in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to supply clean linens in sufficient quantities for resident care needs. This applies to all 98 residents residing in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed provide timely medication administration per facility policy. This applies to 9 residents (R6, R8, R10, R12, R15, R19, R22, R25, and R27) reviewed for medication administration in a sample of 35.

Inspectors wroteBased on interviews and record reviews, the facility failed to staff sufficient nurses for proper incontinence care and timely medication administration. This applies to 11 residents (R6, R8, R10, R12, R15, R17, R19, R20, R22, R25, and R27) reviewed for staffing in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care to residents who required staff assistance for ADLs (Activities of Daily Living). This applies to 2 of 4 residents (R17 and R20) observed for incontinence care in a sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care utilizing techniques per facility protocols and policy. This applies to 3 of 3 residents (R13, R15, and R20) reviewed for incontinence care in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide cold foods to meet acceptable palatable temperatures requirements for the residents. This applies to 5 of 5 residents (R1, R2, R3, R6, R8) reviewed for poor prep and quality of foods.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve protein portion sizes as shown for the lunch meal. This applies to 8 of 10 residents (R1, R2, R3, R4, R5, R6, R7, R9) reviewed for insufficient foods in the sample of insufficient foods in the sample of 10.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to serve palatable meals at temperatures per facility policy. This applies to all 83 residents residing in the facility receiving oral diets.

Inspectors wroteBased on interview and record review, the facility failed to accommodate a resident's food allergies and preferences. This applies to 1 of 3 residents (R1) reviewed for food allergies in a sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from verbal and physical abuse. This applies to 1 of 3 residents (R73) reviewed for abuse allegations in the sample of 18. This failure resulted in R73 feeling traumatized, unsafe, being afraid to sleep, and developing insomnia.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor refrigerator temperatures, failed to label and date potentially hazardous food items, and failed to store food to prevent cross contamination of food items. The facility also failed to ensure dietary staff use facial hair covers while in the kitchen. This failure affects all residents receiving food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to file and respond to resident grievances in accordance with their policy. This applies to 8 of 8 residents (R9, R10, R14, R15, R23, R49, R56, R61) reviewed for grievances in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to residents requiring help with ADL (Activities of Daily Living) care. This applies to 9 of 9 residents (R7, R13, R22, R34, R35, R42, R63, R71 and R72) reviewed for ADL in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence and catheter care in a manner that would prevent urinary tract infections (UTI). This applies to 4 of 6 residents (R7, R10, R13, R56) reviewed for incontinence and urinary catheter care in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to provide bedtime snacks in accordance with their menu. This applies to 5 of 5 (R9, R23, R49, R56, R61) residents who attended the resident counsel meeting and expressed their concerns regarding the availability of bedtime snacks in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement transmission-based precautions as required, failed to perform hand hygiene during provision of care, failed to change gloves during incontinence care and placed soiled linen on the floor. This applies to 7 of 7 residents (R7, R10, R13, R40, R54, R56, R63) reviewed for infection control in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy while providing assistance with a shower. This applies to 1 of 1 resident (R15) reviewed for privacy in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to conduct a thorough staff to resident abuse investigation by not reviewing available video footage of the altercation and not requesting the police report of the incident. This applies to 1 of 3 residents (R73) reviewed for abuse allegations in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dressing change as needed to a resident with a vascular wound. This applies to 1 of 5 residents (R66) reviewed for wounds in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and provide a brace to a resident to prevent further reduction in ROM (range of motion) and to maintain proper positioning. This applies to 1 of 1 resident (R41) reviewed for range of motion in the sample of 18.

Inspectors wroteBased on interview, and record review, the facility failed to document the dialysis communication and assessment after dialysis. This applies to 1 of 2 residents (R64) reviewed for dialysis in the sample of 18. The Findings Include: R64 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with dependence on hemodialysis, type 2 diabetes, hemiplegia, and hemiparesis following cerebral infarction and hypotension of hemodialysis. R64's physician order summary showed R64 has an order for in facility hemodialysis 4 days per week and a left arm A-V (Arterial Venous) fistula to the left arm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activity to a resident who is bed bound and is diagnosed with dementia. This applies to 1 of 4 residents (R7) reviewed for dementia in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform skin assessments in order to prevent pressure injuries from developing for 1 of 5 residents (R2) reviewed for pressure in the sample of 6. This failure resulted in R2 developing a facility acquired pressure injury that was not identified until it was a Stage 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R1) was free of physical abuse from another resident (R2) for 2 of 3 residents reviewed for abuse in the sample of 3. This failure resulted in R2 entering R1's room and hitting R1 over the volume of a TV. R1 sustained multiple facial injuries; abrasions to the left hand and ear; and required evaluation and treatment in the emergency room.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the kitchen was maintained and food was handled in a sanitary manner for all 84 residents in the facility.

Inspectors wroteBased on observation, interview, record review the facility failed to wear appropriate Personal Protective Equipment (PPE) in a contact isolation room, failed to provide a resident with clean eating utensils, and failed to keep fingernails at a safe length to prevent the spread of infection. The has the potential to affect all 84 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were cared for in a dignified manner. This applies to 5 of 18 residents (R11, R12, R18, R26 and R75) reviewed for dignity in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents receiving a pureed diet with the menu as written. This applies to 4 of 18 (R35, R74, R17, and R22) residents reviewed for menus in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to resolve a resident grievance in a timely manner. This applies to 3 of 18 residents (R18, R47 and R70) reviewed for grievances in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers and facial shaving for 2 of 18 residents (R63, R72) reviewed for activities of daily living (ADLs) in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one-to-one assistance during lunch for a resident with a history of dysphagia and aspiration pneumonia (R17), failed to ensure fall interventions were in place for a resident with a history of falls (R50), and failed to ensure a call assistance device was within reach (R63). This applies to 3 of 18 (R17, R50, R63) residents reviewed for safety and supervision in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to honor diet preferences for a resident with a history of significant weight loss. This applies to 1 of 2 residents (R87) reviewed for weight loss in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately and safely dispense medications prior to administration. This applies to 1 of 6 (R44) residents in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to provide a pneumococcal vaccine to residents who consented to receive the vaccine for 2 of 5 residents (R13, R41) reviewed for immunizations in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to develop and implement interventions to manage anxious behaviors for a resident with a diagnosis of dementia. This applies to 1 of 4 (R60) residents reviewed for dementia care in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who requires dialysis received such services per physician's order. This applies to 1 of 4 residents (R1) reviewed for dialysis services in a sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve the correct portion sizes to 70 residents receiving regular diet, 8 receiving Mechanical soft diets, and 7 receiving puree diets, reviewed for insufficient food service. This has the potential to affect all 85 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a clean environment for food preparation and service. The facility failed to monitor sanitization methods for dishware. This applies to 84 of 85 residents reviewed for food storage and preparation.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable meals to residents receiving oral diets. This applies to 4 of 5 residents (R1, R3, R4 and R5) reviewed for meals in a sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure there was a sufficient number of staff to provide nursing services to assure resident safety and maintain their well-being according to their plan of care. This applies to all 84 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to store food in a sanitary manner. This applies to all 84 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to serve food at an appetizing temperature for 6 of 22 residents (R29, R37, R41, R73, R332 and R333) in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nail care was provided for 1 resident (R32), failed to ensure incontinence care was provided in a timely manner for 2 residents (R32, R332), and failed to ensure showers were provided for 2 residents (R19 and R32). This applies to 3 of 22 residents (R19, R32 and R332) reviewed for Activities of daily living (ADL's) in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oral care and treatments for a resident with mouth ulcers and failed to ensure wound treatments were completed as order for a resident with a non pressure wound for 2 of 22 residents (R21, R54) in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure injury interventions were administered as ordered and failed to ensure dressing changes were performed in a manner to prevent infection for 2 of 6 residents (R21, R51) reviewed for pressure in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative services were being provided to 1 of 12 residents (R73) reviewed for restorative in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident, at risk for choking and aspiration, consumed foods that were pureed in consistency. The facility failed to ensure a resident was transferred in a safe manner. The facility failed to identify and assess a resident at risk for elopement. These failures apply to 3 of 22 residents (R78, R33, R25) reviewed for safety and supervision in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain urinary indwelling catheters in a manner to prevent infection for 2 of 8 residents (R60, R21) reviewed for urinary catheters in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to feed and/or provide assistance with eating to residents with significant weight loss. These failures apply to 2 of 13 residents (R4, R67) reviewed for weight loss in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered (at ordered times or in ordered dosage). There were 34 opportunities with 12 errors resulting in a 35.29% error rate. This failure applies to 2 of 7 residents (R67, R36) observed in the medication pass.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered on time to prevent a significant medication error for 1 of 22 residents (R282) reviewed for medications in the sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a residents room had a functioning call light for 1 of 22 residents (R59) reviewed for call lights in the sample of 22.