Oakwood Specialty Care

Inspectors wroteBased on observation, clinical record review, staff interview, and facility policy review the facility failed to perform appropriate hand hygiene during personal cares for one of two residents observed for toileting hygiene (Res #3). The facility reported a census of 50 residents.

Inspectors wroteBased on record review, Facility Assessment and staff interviews, the facility failed to maintain an adequate number of staff for the facility's census. The facility reported a census of 50 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to maintain clean and sanitary conditions in the kitchen, failed to label and store food items and discard leftovers after 3 days in order to maintain food quality and reduce the risk of food-borne illness in the kitchen and the designated resident's refrigerator for one of one nursing units observed. Facility staff also failed to wash hands to prevent food borne illness. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, menu review, record review, and staff interviews, the facility failed to serve the appropriate portions for 4 of 4 residents who received pureed diets (Resident #9, #12, #27, and #31) and 10 of 10 residents on a mechanical soft diet (Resident #4, #7, #18, #19, #25, #28, #30, #35, #37, and #47). The facility reported a census of 50 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to prepare and serve all foods at a safe and palatable temperature in order to prevent foodborne illness for 1 of 1 meals observed. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to maintain accurate medical records for 1 of 18 residents (Res #26) reviewed. The facility reported a census of 50 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination of invasive medical equipment for 1 of 1 resident reviewed (#12). The facility reported a census of 50 residents.

Inspectors wroteBased on observations, staff interview and resident interviews, the facility failed to serve room trays at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care, by delaying room tray delivery for the lunch meal past 1:00 p.m. The facility reported a census of 48.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, the facility failed to ensure residents are provided bathing opportunities for 2 of 3 residents dependent on staff. (Residents #2, #6) The facility reported resident census of 48.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to answer call lights within a reasonable amount of time. (Residents #2, #6, #7, #8) The facility reported resident census of 48.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to administer medications as ordered for 4 of 11 residents reviewed for medication administration (Residents #1, #14, #16, #23) and failed to administer the correct nutritional feeding for 1 of 1 residents reviewed with a Gastrostomy Tube(g-tube-a tube inserted into the stomach through the abdomen) (Resident #38). The facility reported a census of 34 residents.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to follow proper sanitation and food handling practices during the initial pool and for 1 of 1 meal observed. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, observations, staff interview and facility policy, the facility failed to provide clean bed linens for 1 of 16 residents reviewed for homelike environment (Resident #7).

Inspectors wroteBased on record review, Resident Assessment Instrument (RAI) manual v1.17.1_October 2019, and staff interview, the facility failed to complete a comprehensive assessment of a resident's needs within 14 days of admission for 1 of 15 residents (Resident #38) for Minimum Data Set (MDS) requirements. Findings Include: The Entry Minimum Data Set (MDS) of Resident #38 dated 5/30/23 identified the resident had an admission date to the facility of 5/20/23. Section 2.5 of the RAI manual, dated October 2019, defines admission as the date a person enters the facility and is admitted as a resident. The RAI documented an admission assessment must occur in any of the following admission situations: · when the resident has never been admitted to this facility before; OR · when the resident has been in this facility previously and was discharged return not anticipated; [...]

Inspectors wroteBased on interview and record review the facility failed to accurately document the functional status and the anticoagulant medications on the MDS (Minimum Data Set) assessment for 2 of 15 residents reviewed (R# 16, R#23). The facility reported a census of 34. Findings Include: 1. The Annual MDS assessment dated [DATE] revealed Resident #23 scored 4 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired. The MDS revealed medical diagnosis of non-traumatic brain dysfunction; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and unspecified lack of coordination. The MDS revealed the resident did not transfer between surfaces including to or from the bed, chair or wheelchair during the 7 day look back period. [...]

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for weight loss (Resident #24). The facility reported a census of 34 residents. Findings Include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/31/23, listed diagnoses for Resident #24 which included non-Alzheimer's dementia, seizure disorder, and moderate intellectual disabilities. The MDS stated the resident required extensive assistance of 1 staff for eating and listed the resident's Brief Interview for Mental Status(BIMS) as 0 out of 15, which indicated severely impaired cognition. During an observation on 6/14/23 at 8:09 a.m., the resident sat at breakfast and had a glass of red liquid and a water. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to assess pain or carry out interventions to relieve pain for 1 of 2 residents reviewed for pain (Resident #11). The facility reported a census of 34 residents.

Inspectors wroteBased on facility records, staff interview and policy review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met on a quarterly basis.