The Springs of Red Oak

Inspectors wroteBased on observation, interview, and facility policy review, it was determined that the facility failed to ensure food preparation and serving pieces were washed, dried, and stored in sanitary conditions for one of one kitchen. Based on observation, interview, and facility policy review, it was determined that the facility failed to ensure food preparation and serving dishware were washed, dried, and stored in sanitary conditions for one of one kitchen that served 35 residents with regular diets, 11 with mechanical soft diets, and two with pureed diets.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure proper infection prevention measures during a medication administration for 1 resident (Resident #40) out of 4 residents observed to be given medications. Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure proper infection control during medication administration for one (Resident #40) of four residents observed during medication administration.

Inspectors wroteBased on observations, interview, record review, and facility policy review the facility failed to ensure dignity was maintained for 1(Resident #21) of 1 sampled resident reviewed for dignity.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure confidentiality of personal and medical information was protected for 1 (Resident #21) of 1 sampled resident reviewed for personal and medical information confidentiality.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to coordinate with state authority to determine if placement in the facility was appropriate or incorporate the Pre-admission Screening and Resident Review (PASARR) assessment with if any recommendations from the level II determination and the PASARR evaluation report into the resident assessment, care planning, and transition of care for 1 (Resident #46) of 1 sampled resident reviewed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a comprehensive care plan was developed to address the necessary monitoring and precautions related to the use of tobacco products to meet the needs of the resident and minimize the potential for complications for 1 (Resident #55) of 1 sampled resident who was reviewed for tobacco use.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to develop a discharge summary which included a recapitalization of the resident's stay, a final summary of the resident's status, and reconciliation of all pre and post discharge medications for 1 (Resident #111) of 3 sampled residents.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure 1 (Resident #39) of 1 sampled resident received wound care according to the physician's order.

Inspectors wroteBased on document review, observations, interviews, and facility policy review, the facility failed to post the nurse staffing information on a daily basis, to include the facility name, the current date, the number and actual hours worked by staff, and the resident census. The deficient practice had the potential to affect all residents.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure gradual psychotropic (anti-anxiety) dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the as needed (PRN) medication past 14 days and a documented explanation as to why a dose reduction attempt would be contraindicated, in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1(Resident # 43) of 1 sampled resident.

Inspectors wroteBased on record review and interview, the facility failed to develop and/or implement a water management program with measures to minimize the risk for Legionella and other waterborne opportunistic pathogens to reduce the risk for potential infections. This failed practice had the potential to affect 38 residents who resided in the facility.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the indwelling catheter tubing was anchored to prevent trauma and positioned to allow the urine to flow down away from the bladder for 1 (Resident #30) of 1 sampled resident and failed to ensure a catheter bag was not touching the floor to decrease the potential for infection for 2 (Residents #4 and #30) of 2 sampled residents who had a physician's order for an indwelling catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multi-dose insulin vials were dated when opened and discontinued or expired medications were removed and placed into an area for destruction to prevent potential administration to residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure parameters were put in place to ensure the correct dosage of oxygen was administered to enable the Physician to determine the dosage needed for 1 (Resident #4) sampled resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure Pneumococcal immunizations were administered to eligible residents and the immunization records were updated in the electronic health records (EHR) for 1 (Resident #22) of 5 (Residents #4, #5, #21, #22 and #32) sampled residents whose immunization information was reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure transportation provider safely off-loaded a resident in a wheelchair from the facility transportation van to prevent potential injury for 1 (Resident #1) of 2 (Residents #1 and #2) sampled residents who required transport in a wheelchair on the transportation provider's van. The failed practice had the potential to affect 46 residents that resided in the facility per census received 2/7/2024. This failed practice resulted past Immediate Jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who rolled out of the van in a manual wheelchair and fell on the lift that was ground level resulting in a back injury. The facility was notified of the past Immediate Jeopardy on 2/8/2024 at 2:00 pm.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all alleged violations involving a fall with major injury was reported immediately, but not later than 2 hours after major injury was discovered for 1 (Resident #1) of 1 sampled resident who had a report for fall during off-loading from facility transport van since December 2023.

Inspectors wroteBased on record review and interview, the facility failed to review and revise the care plan and reassess the effectiveness of interventions to meet the resident needs for 2 (Residents #1 and #3) of 3 sampled residents.