Oakwood Village East Health and Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives care consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 1 sampled residents (R2), out of a total sample of 3 residents reviewed. The facility inaccurately assessed R2's risk of skin breakdown. The facility failed to create a robust plan of care to prevent PI development. The facility failed to update R2's care plan timely with interventions to prevent worsening pressure injuries or prevent more injuries from developing. Staff inconsistently staged R2's wound and failed to describe characteristics of the wound bed in weekly assessments. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (R1) reviewed for foley catheter (a thin, flexible tube inserted into the urethra to drain urine from the bladder) management. The facility manipulated and removed R1's foley catheter against physician orders. This is evidenced by:The facility's policy Change in a Resident's Condition or Status, dated 2/21, includes: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a(an): need to alter the resident's medical treatment significantly. [...]

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. This had the potential to affect all 33 residents. One staff member returned to work too soon after experiencing GI (gastrointestinal) symptoms. Five staff members on the facility’s line list did not have the date of last symptoms listed. R63 and R13, did not have accurate symptoms reflected on the line listing. Staff did not perform appropriate hand hygiene per Standards of Practice while providing catheter care to R6. This is evidenced by: The facility policy entitled Communicable/Contagious Diseases, Employee, with a revision date of December 2024, states in part:“Policy Statement: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 5 of 5 abuse investigations reviewed involving 1 of 1 sampled Residents (R1) and 4 of 4 supplemental Residents (R35, R61, R62 and R60). Facility became aware of an abuse allegation involving R1 on 12/4/24 and 7/14/25 and failed to report the allegations to the State Agency. R35 and R35’s representative (RR P) used the concerns/grievance process to voice a concern regarding unwanted touching of her vaginal area by LPN K (Licensed Practical Nurse) even after she asked him to stop. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation of abuse/exploitation was completed for 1 of 1 sampled Residents (R1) and 4 of 4 supplemental Residents (R35, R61, R62 and R60) reviewed for abuse. Facility became aware of an abuse allegation involving R1 on 12/4/24 and 7/14/25 and failed to complete a thorough investigation. R35 and R35’s Resident representative (RR P) used the concerns/grievance process to voice a concern regarding unwanted touching of her vaginal area by LPN K (Licensed Practical Nurse) even after she asked him to stop. The facility failed to conduct a thorough investigation of the incident. CNA O (Certified Nursing Assistant) heard RN S (Registered Nurse) yelling at R60 and intervened. CNA O observed RN S pull R60’s blanket off without warning and throw it on the floor. [...]

Inspectors wroteBased on record review and interview the facility did not complete the PASARR Level II (Preadmission Screening and Resident Review) when it was realized that 4 of 4 Residents (R3, R40, R6, & R14) would reside in the facility for more than 30 days. R3, R40, R6, and R14 were admitted to the facility with diagnoses that included a major mental disorder and were prescribed medication to treat symptoms of a major mental disorder. R3, R40, R6, and R14 resided in the facility for more than 30 days and no evidence was provided that a PASRR Level II Screen was completed for R3, R40, R6, and R14. Evidenced by: The Preadmission Screen and Resident Review Level 1 Screen directions include, in part, the following: [...]

Inspectors wroteNumber of residents sampled: 12Number of residents cited:1Based on record review and interview, the facility failed to ensure resident's advanced directives were accurate and up to date in the resident's electronic medical records for 1 of 12 residents (R20) reviewed for advanced directives. R20's CPR (Cardiopulmonary Resuscitation) preference form indicated he wanted CPR attempts and R20's electronic medical record reflected he was a DNR (Do Not Resuscitate). This is evidenced by:The facility's policy titled Advance Directives, dated 9/22, includes the following: The resident has the right to formulate an advance directive. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents' right to be free from verbal abuse, mental abuse, and sexual abuse by staff for 2 of 8 Residents Reviewed for abuse (R35 and R60). R35 and R35's representative (RR P) used the concerns/grievance process to voice a concern regarding unwanted touching of her vaginal area by LPN K (Licensed Practical Nurse) even after she asked him to stop. CNA O (Certified Nursing Assistant) heard RN S (Registered Nurse) yelling at R60 and intervened. CNA O observed RN S pull R60's blanket off without warning and throw it on the floor. CNA O observed RN S slam R60's room door and bathroom door. CNA O reported the allegation of verbal abuse/mental abuse to DON B (Director of Nursing). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 6 supplemental residents (R41 and R63) reviewed for antibiotic stewardship. A UTI (urinary tract infection) was not documented on the line list for R63. The UTI that was documented had incomplete information. The facility did not obtain a C&S (culture and sensitivity) for R63's UA (urinalysis) results or complete a McGeer Criteria checklist to indicate if UTI criteria was met. There was incorrect documentation on the line list for R41 and the facility did not show that the antibiotic was necessary. This is evidenced by:The facility policy entitled Antibiotic Stewardship - Orders for Antibiotics, with a revision date of December 2016, states in part: Policy Statement: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunization; and (B) That the resident either received the influenza and/or pneumococcal immunization or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. This affected 1 of 5 residents (R3) reviewed for immunizations. R3 did not sign, date, or check consent or declination for the influenza vaccination for 2024/2025 until 7/29/25. This is evidenced by:The facility policy entitled Influenza Vaccine, with a revision date of March 2022, states in part: Policy Statement: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 36 residents residing at the facility. Surveyor observed no lids on the garbage cans in the kitchenettes. Garbage cans were placed near food prep/serve area. Surveyor observed no lids on the garbage cans near the food prep area in the main kitchen. Surveyor observed crumbs and dried on substance in the containers where the spatulas and spoons are kept in the main kitchen. Surveyor observed staff not following standard practice for temping food. Surveyor observed kitchenettes on 1st and 2nd floor to have crumbs and dust inside cupboards. Surveyor observed the microwave on the 1st floor to have dried on food inside microwave. [...]

Inspectors wroteBased on interview and record review, the facility has not established 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. This has the potential to affect all 36 residents (R) in the facility. The facility failed to identify a COVID-19 outbreak when OT H (Occupational Therapy) tested positive for COVID-19. The facility did not recognize Centers for Disease Control and Prevention (CDC) guidance as one positive COVID-19 positive resident or staff qualified as an outbreak. The facility failed to notify public health of a COVID-19 outbreak per CDC guidelines. The facility failed to notify the Medical Director (MD) of a COVID-19 outbreak. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 4 of 5 residents (R11, R10, R13, and R32) reviewed for unnecessary medications. R11 was prescribed psychotropic medications without adequate monitoring of side effects, individualized behavior monitoring, or non-pharmacological approaches/interventions utilized. R10 was prescribed a hypnotic without a sleep assessment, an antipsychotic medication and an antidepressant medication without individualized behavior monitoring, and non- pharmacological approaches/ interventions utilized. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 12 (R5) sampled residents and 4 of 4 (R9, R23, R4, R291) supplemental residents reviewed for antibiotic stewardship. R9 was on antibiotic for urinary tract infection without an appropriate indication. Facility did not have documentation of Urinalysis (UA) and Culture and Susceptibility (C&S). R23 was on antibiotic for urinary tract infection without an appropriate indication. R4 was on antibiotic for urinary tract infection without an appropriate indication. R5 was on antibiotic for urinary tract infection without an appropriate indication. Facility did not have documentation of an UA and C&S. R291 was on antibiotic for urinary tract infection without an appropriate indication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that self-administration of medications was determined to be clinically appropriate for 1 (R10) of 1 residents reviewed out of a sample of 12 residents. Surveyor observed R10 to have medication sitting on the nightstand. R10 indicated it is an as needed medication (PRN) and was unable to remember if a self-administration assessment was completed. Evidenced by: The facility did not provide a Self-Administration policy. R10 was admitted to the facility on [DATE] with diagnoses including fracture of left foot, need for assistance with personal care, history of falling, cognitive communication deficit, abnormalities of gait and mobility, muscle weakness, kidney disease, depression, bipolar, edema, and reflux disease. On [DATE] at 9:23AM, Surveyor met R10. [...]

Inspectors wroteBased on interview and record review the facility did not develop a comprehensive person-centered care plan for 2 of 5 residents (R11 and R32) reviewed for unnecessary medications. R11 does not have a care plan for the use of an antidepressant medications and an antianxiety medication. R32 does not have a care plan for the use of antidepressant medication. This is evidenced by: The facility's policy titled Psychotropic Drug Use, dated 11/1/21, states in part: .admission Orders or Initiation of Psychotropic Medication Use .5. Nurse will initiate behavior monitoring for behaviors specific to resident. Targeted behavior monitoring will be recorded in the Medication Administration Record (MAR). 6. Nurse/ Social Worker will update Care Plan including goals and interventions, including non- pharmaceutical approaches. 7. [...]