Pataskala Oaks Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen environment and store food in a sanitary manner. This deficient practice has the potential to affect all residents who receive meals prepared in the facility kitchen. The facility identified four residents (#32, #73, #81, and #90) who received nothing by mouth. The census was 58.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were educated on the risks/ benefits associated with the use of psychotropic medications, and informed consent was obtained from the resident and/ or their representative prior to use. This affected five (Resident #1, #5, #27, #30, and #35) of five residents reviewed for unnecessary medications. The facility census was 50.

Inspectors wroteBased on interviews and record reviews, the facility failed to obtain an assessment and physician order for a wander guard for one resident (#5) out of one resident reviewed for restraints. In addition, based on observation, interview, record review and policy review, the facility failed to timely change PICC (peripherally inserted central catheter) line access dressings as ordered for three residents (#2, #21 and #33) of three residents reviewed. The facility census was 50.

Inspectors wroteBased on interview, record review, observation and facility policy review, the facility failed to implement preventive pressure ulcer skin interventions for 5 residents (#33, #2, #18, #4, and #63.) of 5 reviewed. The facility census was 50.

Inspectors wroteBased on record review, facility policy review, and staff interview the facility failed to accurately reflect the Resident code status in the electronic medical record and the paper copies in the facility binder used for emergencies. This affected two Residents (Resident #3 and #5) of the 22 residents reviewed for code status. The facility census was 50. Findings Include:1. Review of Resident #3 medial record revealed admission to facility 04/22/24 for diagnoses including chronic obstructive pulmonary disease, diabetes mellitus type 1 with neuropathy (decreased sensation in nerve endings), high blood pressure, major depressive disorder, unspecified mood disorder, generalized anxiety disorder, unspecified disorders of adult personality and behavior, insomnia (inability to sleep), heart disease, chronic kidney disease. Review on 08/18/2025 at 11:53 A.M. [...]

Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) documents accurately reflected diagnoses. This affected three (Resident #5, #3 and #8) of three residents reviewed for PASRR documents. The census was 50. Findings Include: 1. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including nontraumatic chronic subdural hemorrhage, cerebral infarction, hypertension, diabetes mellitus, major depressive disorder (MDD), anxiety disorder, post-traumatic stress disorder (PTSD), hemiplegia and hemiparesis, and congestive heart failure. Review of the annual Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #5's Brief Interview for Mental Status (BIMS) score was 09 out 15, which indicated moderately impaired cognition. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's comprehensive care plans included care plans to address all the resident's diagnoses that they received medications for. This affected one (Resident #35) of 22 residents reviewed for care plans. The facility census was 50.

Inspectors wroteBased on record review, interview, and observation, the facility failed to maintain safe equipment for residents, which affected Resident #27. The facility also failed to maintain safety for Resident #10 identified as being a high fall risk. This affected two residents ( #10 and #27) out of 3 residents reviewed for accidents. The facility census was 50.1. Review of the medical record for Resident #27 revealed an admission date of 01/08/24. Diagnoses included but were not limited to: Unspecified Atrial Flutter; Pain; Rhabdomyolysis, unspecified fall; Essential Hypertension; Unspecified Heart Failure, Chronic Obstructive Pulmonary Disease with Lower Respiratory Infection; Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms; Ventricular Flutter; Malignant Neoplasm of Bladder; [...]

Inspectors wroteBased on policy review, record review, observation and interview, the facility failed to properly administer oxygen per nasal cannula as ordered by a physician. This affected three (Resident #12, Resident #27, and Resident #61) of three residents reviewed for oxygen use. The facility census was 50.

Inspectors wroteBased on record review, resident observations, policy review, and interviews, the facility failed to assess and implement trauma informed care for two Residents (Residents #5 and #24) of the two residents reviewed for trauma informed care. The facility census was 50. Findings Include: 1. Record review of Resident #24 revealed admission to facility on 03/12/20 with diagnosis including chronic kidney disease, cerebral atherosclerosis (blockage of vessels in the brain), hearing loss of right ear, dysphagia (difficulty swallowing), chronic cough, attention deficit hyperactivity disorder (ADHD), dementia (forgetfulness), diabetes mellitus type II, major depressive disorder, anxiety, mild cognitive impairment of unknown etiology, insomnia (inability to sleep), heart disease, and lung disease. [...]

Inspectors wroteBased on observation, record review and policy review, the facility failed to provide proper cleaning/disinfection of equipment between resident use. This affected two (Resident #32 and #12) of eight residents (Resident #5, Resident #9, Resident #12, Resident #27, Resident #32, Resident #34, Resident #45, and Resident #61) identified on Middle Hall as requiring blood pressures prior to medication administration and one (Resident #19) of one reviewed for glucometer use. The facility census was 50. Findings Include: 1. On 08/20/2025 at 8:16 A.M., observation revealed Registered Nurse (RN) #33 took Resident #32's blood pressure using an electronic blood pressure monitor. She did not sanitize the blood pressure cuff at that time. RN #33 then completed the medication administration of this resident. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to maintain an effective antibiotic stewardship program by not ensuring a resident was not started on an antibiotic for a suspected urinary tract infection until a urinalysis culture result was received to identify best course of treatment. This affected one (Resident #8) of four residents reviewed for urinary tract infections. The facility census was 50.

Inspectors wroteBased on observation, interview, review of manufacturer guidelines, and facility policy review, the facility failed to date a multi-dose vial of Tubersol tuberculin solution when opened for use. This deficient practice had the potential to affect 12 residents who were newly admitted after the tuberculin solution was received from the pharmacy. The facility census was 50. Findings Include: An observation on 04/23/24 at 7:43 A.M. revealed an in use opened multi-dose vial of Tubersol tuberculin solution in the medication refrigerator located in the facility medication room. There was a yellow sticker on the bottom of the vial with the word date written on it. There was no opened date written on the sticker, on the vial or on the box were the vial was stored. The storage box had a label from the pharmacy with a delivery date to the facility of 03/07/24. Interview on 04/23/24 at 7:50 A.M. [...]

Inspectors wroteBased on observation, interview, and review of facility policy the facility failed to ensure five residents (#11, #27, #28, #37, and #49) on a mechanically altered diet were served food at an appropriate texture. This affected five residents (#11, #27, #28, #37, and #49) of 15 residents on a mechanically altered or soft diet. The facility census was 50.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to use appropriate hand hygiene during meal service. This had the potential to affect 46 of 46 residents who consumed food from the kitchen. The facility identified four residents (#25, #42, #46, #51) who were unable to eat by mouth. The facility census is 50.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete a bed hold notice within 24 hours of a resident's discharge to the hospital. This affected one resident (Resident #55) out of four residents reviewed for hospitalization. The facility census was 50. Findings Include: Review of Resident #55's medical record revealed Resident #55 was admitted to the facility on [DATE] and was sent to the hospital on [DATE] for evaluation of altered mental status and was discharged from the facility on 02/05/24. Review of Resident #55's medical record revealed Resident #55 primary payer was Ohio Medicaid which requires notification to resident's representative the option to hold the resident's bed at the facility following a discharge to the hospital. There was no bed hold notice found in Resident #55's medical record. Interview on 04/23/24 at 10:02 A.M. [...]

Inspectors wroteBased on observation, record review, interviews, and facility policy review the facility failed to apply and document the use of a left elbow brace to decrease the decline of contracture. This affected one resident (Resident #5) out of two residents reviewed for position and mobility. The facility census was 50. Findings Include: Review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses including Cerebral Palsy, high blood pressure, and type two diabetes mellitus. Resident #5 required assistance from staff to complete personal care tasks, transfers, and bathing. Resident #5 had mild cognitive impairment and used a wheelchair for mobility. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed in section O - Special Treatments, Procedures, and Programs splint or brace assistance was not marked. [...]

Inspectors wroteBased on interview, record review, and review of facilities investigative report, the facility failed to ensure Resident #39 received the appropriate assistance, resulting in a fall. This affected one resident (#39) of two residents reviewed for falls. The facility census was 50.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to change oxygen and nebulizer tubing as ordered. This affected one resident (Resident #14) out of two residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including asthma, high blood pressure, dementia, and weakness. Resident #14 had severe cognition impairment, required staff assistance for personal hygiene cares, transfers, and bathing. [...]

Inspectors wroteBased on staff interview, review of medical records, and facility policy, the facility failed to provide non-pharmacological interventions, properly document pain location and indicators of pain, with the administration of as needed pain medication. This affected one resident (Resident #46) of five residents reviewed for unnecessary medications. The facility census was 50.

Inspectors wroteBased on staff interview, medical record review, and review of facility policy, the facility failed to ensure an end date was documented for an as needed psychotropic drug order, document behaviors and ensure non-pharmacological interventions were attempted prior to administration of as needed psychotropic drug for Resident #46, and to complete Abnormal Involuntary Movement Scale (AIM) assessments as scheduled for two residents (#19 and #38). This affected three residents (#46, #38, #19) of five residents reviewed for unnecessary medications. The facility census was 50.

Inspectors wroteBased on observation, interview, review of facility policy, and medical record review, the facility failed to ensure puree food was served according to the menu and at an appropriate texture. This affected one resident (#35) of one resident on a puree diet. The facility census was 50.

Inspectors wroteBased on observation, record review, and interview the facility failed to accurately document a physician order by signing that an order had been completed when the order had not been completed by not changing oxygen and nebulizer tubing as documented. This affected one resident (Resident #14) out of two residents reviewed for respiratory care. The facility census was 50. Findings Include: Review of Resident #14's medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including asthma, high blood pressure, dementia, and weakness. Resident #14 had severe cognition impairment, required staff assistance for personal hygiene cares, transfers, and bathing. [...]

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to perform hand hygiene during wound care. This affected one resident (Resident #34) out of four residents reviewed for pressure ulcer/injury. The facility census was 50. Findings Include: Review of Resident #34's medical record revealed Resident #34 was admitted to the facility on [DATE] and re-admitted from a hospital stay on 04/19/24 with diagnoses including pressure injury to sacrum, bacteremia (blood infection), high blood pressure, depression, and bilateral above the knee amputations. Resident #34 had minimal cognitive impairment and required assistance from staff for Activities of Daily Living (ADL) tasks, transfers, and medical treatments. [...]

Inspectors wroteBased on observation, policy review, and interview, the facility failed to provide a safe and comfortable environment for residents when the front hallway and back hallway were cluttered providing an increased risk of falls or accidents for residents. This affected 12 residents (#3, #5, #11, #17, #19, #22, #25, #33, #44, #57, #87, and #89) of 52 residents in the facility.

Inspectors wroteBased on observation, interview and policy review, the facility failed to store cold sandwiches and milk at the appropriate temperatures to prevent potential for food borne illness. This had the potential to affect 46 of 52 residents who consume food and beverages provided by the facility. The facility census was 52.

Inspectors wroteBased on staff interview and review of a personnel file, the facility failed to ensure the activity director met the minimum qualifications, training, and/or experience for an activity director. This had the potential to affect all 61 residents residing in the facility. The census was 61.

Inspectors wroteBased on open and closed medical record reviews, interviews with staff, review of side effects for Paxlovid (an antiviral medication), review of interaction warning for Paxlovid medication, review of fact sheet on Paxlovid, review of hospital records, and facility policy review, the facility failed to adequately monitor residents for signs and symptoms of bleeding while taking an anticoagulant medication. This resulted in Immediate Jeopardy and serious life-threatening harm on [DATE] when Resident #56 was prescribed Paxlovid (an antiviral medication) twice daily for five days to treat COVID-19 infection while also taking Rivaroxaban (generic brand for Xarelto), an anticoagulant medication. [...]

Inspectors wroteBased on medical record review, review of hospital records, review of a fall investigation, facility policy review, and staff interviews, the facility failed to provide effective pain management to Resident #23 following a fall on 05/21/22 that resulted in two fractured ribs. This affected one resident (#23) of one resident reviewed for pain management. The facility census was 59. Actual Harm occurred to Resident #23 on 05/21/22 when the resident was not provided effective pain relief until being transferred to the hospital on [DATE] at 11:21 P.M. (nearly two days after the fall occurred) where subsequent additional treatment was provided to the resident for effective pain management. During the time period between the fall and the hospitalization the resident complained of increased pain, ineffective pain medication (Tylenol) and feeling fatigued due to an inability to sleep. [...]

Inspectors wroteBased on review of the staff vaccination matrix, staff interview, and facility policy review, the facility failed to ensure all staff were vaccinated against the COVID-19 virus or had a valid exemption on file prior to working in the facility. This had the potential to affect all 59 residents who resided in the facility. Findings Include: Review of the Staff Vaccination Matrix dated 03/15/23 revealed Dietary #180 was listed as unvaccinated. The facility had a total of 84 staff and 83 staff were either vaccinated or had a religious exemption on file. Interview on 03/14/23 at 1:34 P.M. with the Director of Nursing (DON) revealed the facility had a total of 84 staff; 19 staff had religious exemptions on file. One staff, Dietary #180 was unvaccinated. Dietary #180 was contacted on 03/13/23 and should be attending a vaccine clinic on 03/16/23. Interviews on 03/15/23 at 3:48 P.M. and 5:30 P.M. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure pre-admission screening and resident review (PASARR) for individuals with mental disorders was accurate. This affected four (Resident #14, #16, #19 and #42) of four residents reviewed for preadmission screening. The census was 59.

Inspectors wroteBased on medical record review, staff interview and facility policy and procedure review, revealed the facility failed to ensure monthly pharmacy reviews are completed. This affected six residents (#16, #25, #28, #30, #42, and #258) of 11 residents reviewed for unnecessary medications. The census was 59.

Inspectors wrote4. Review of Resident #16's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, schizoaffective disorder, vascular dementia, anxiety, paranoid schizophrenia, and major depressive disorder. Review of the annual MDS dated [DATE] revealed his cognition was not intact. He required limited assistance of one staff member for bed mobility, transfer, and extensive assistance of one staff member for dressing, toilet use and personal hygiene. Review of the Pharmacy recommendation for 02/25/23 revealed Resident #16 has been taking Latuda 40 mg daily for bipolar disorder since March 2022. Please evaluate the potential for a dose reduction at this time to determine the lowest, effective dose. If contraindicated please provide a brief note. 5. Review of Resident #42's medical record revealed he was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #19) of one resident reviewed for advanced directives. The facility census was 59. Findings Include: Record review for Resident # 19 revealed the resident was admitted on [DATE] with medical diagnoses of Alzheimer's disease, post- traumatic stress disorder, dysphagia, dementia, depression, [NAME] insufficiency, polyosteoarthritis, peripheral vascular disease, apraxia, anxiety disorder. Review of the most recent Minimum Data Set 3.0 assessment dated [DATE] revealed the resident did not answer or did not cooperate with many sections of the assessment. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to notify one resident's (Resident #30) nephrologist of laboratory test results as ordered by the physician. This affected one (Resident #30) of one reviewed for notification of change. The facility census was 59. Findings Include: Review of Resident #30's medical record revealed an original admission date on 06/09/21 and a readmission date on 07/12/21. Medical diagnoses included chronic obstructive pulmonary disease (COPD), hyperkalemia, Type II Diabetes Mellitus, and hypertensive chronic kidney disease with end stage renal disease. Review of lab orders revealed Resident #30 had the following lab orders: [...]

Inspectors wroteBased on medical record review, policy review, and staff interview, the facility failed to ensure treatment orders were completed for residents with cardiac and blood pressure medical conditions. This affected two residents (#30 and #42) of five residents reviewed for unnecessary medications. The census was 59.

Inspectors wroteBased on medical record review, staff interview, and observation revealed the facility failed to ensure pressure ulcer treatment and interventions were in place for two residents (#17 and #28) of four residents reviewed for pressure ulcers. The census was 59.

Inspectors wroteBased on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure respiratory equipment was stored appropriately to prevent infection. This affected one resident (#17) of two residents reviewed for respiratory care. The census was 59.