The Oaks Post Acute

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in 1 of 1 Kitchen, 1 of 3 Unit Nourishment Rooms, and 1 of 1 Medication Rooms. Review of the facility policy titled Food Receiving and Storage last revised in July 2014 revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Refrigerated foods must be stored below 41F unless otherwise specified by law. [...]

Inspectors wroteBased on review of facility policy, observation, record review, and interview, the facility failed to maintain a clean, homelike environment for Residents (R)57, R71, and R95 for 2 of 3 units observed.

Inspectors wroteBased on review of facility policy, observation, record review, manufacturer labeling and interview, the facility failed to ensure proper storage of medications in 2 of 3 medications rooms and 1 of 6 medications carts.

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to provide quarterly account statements for Resident (R)7's personal fund for 1 out of 1 resident reviewed for Personal Funds.

Inspectors wroteBased on review of facility policy, observation, record review, drug manufacturer recommendation and interview, the facility failed to notify a medical doctor or nurse practitioner of a clinical concern related to Resident (R)23. Furthermore, the facility failed to maintain stock of an ordered medication for R6.

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to ensure proper usage or the hoyer lift, for 1 of 1 Resident R(49), reviewed for accident hazards/supervision/devices.

Inspectors wroteBased on facility policy review, observation, record review and interview, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure Resident (R)122's nebulizer machine, oxygen mask and medication chamber were clean and stored properly when not in use for 1 of 1 resident.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to provide a safe and sanitary environment to help decrease the risk of infections. Specifically, the facility failed to offer residents hand hygiene prior to dining in the 400 Riverside Unit. Furthermore, the facility failed to prevent potential cross-contamination by housekeeping staff. Review of the facility policy titled Handwashing/Hand Hygiene with a revision date of October 2023, revealed, The Oaks Post Acute Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation: Administrative Practices to Promote Hand Hygiene: . 3. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that Resident (R)3 was free from misappropriation by Certified Nursing Assistant (CNA)1, for 1 of 3 residents reviewed for misappropriation or property.

Inspectors wroteBased on review of facility policy, record review and interview, the facility failed to accurately document Fall Risk Assessments, for 1 of 3 residents, Resident (R)1, reviewed for accidents/falls. This failure placed R1 at an increased risk for falls and injuries.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure biologicals and supplements were stored appropriately.

Inspectors wroteBased on interview, record review, and facility policy the facility failed to ensure that Resident (R)163, a resident with an Advanced Directive as Full Code received Cardiopulmonary Resuscitation (CPR) after being found unresponsive on 10/09/24. 1 of 1 reviewed for CPR. On 11/04/24 at 7:15 PM the Administrator and Director of Nursing (DON) were notified that the failure to initiate CPR on R163 on 10/09/24 after being found unresponsive constituted an Immediate Jeopardy (IJ). The IJ was determined to first exist on 10/09/24 at approximately 4:10 PM (time of death according to County Coroner's Office/ Electronic Medical Record). The facility presented a removal plan on 11/05/24 at 5:52 PM, the deficient practice remained at F678 at a lower scope and severity of D, the facilities failure constituted substandard quality of care at F678. [...]

Inspectors wroteBased on review of the facility policy, observations and interviews, the facility failed to ensure biologicals were stored appropriately in 3 of 3 Medication Treatment Carts.

Inspectors wroteBased on observations and interviews the facility failed to ensure that the ice machine in 1 of 1 kitchen was kept clean and sanitized.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to develop a Care Plan for Resident (R)163, related to Advance Directives, for 1 of 2 residents reviewed.

Inspectors wroteBased on review of facility policy, observation, interview, and record review, the facility failed to ensure Resident (R)52, who was dependent on staff for activities of daily living (ADLs), received the necessary services to maintain personal hygiene, for 1 of 6 residents reviewed.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to notify Resident (R)1's responsible party (RP) of a change in skin condition when an unstageable wound was discovered for 1 of 3 records reviewed for quality of care.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to ensure a written grievance was filed for Resident (R)1 regarding care concerns for 1 of 3 residents reviewed for quality of care.

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed accurately for 3 of 3 residents (Resident (R)77, R17, and R60) reviewed for PASRR.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted within the 14-day period for 1 of 1 Resident (R)1, reviewed for resident assessments.

Inspectors wroteBased on review of the facility policy, record review, and interview, the facility failed to ensure insulin was provided according to the sliding scale the Physician ordered for 1 (Resident (R)17) of 1 resident reviewed for insulin administration.