Three Oaks Health Services

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure proper disposal of garbage and refuse.-Grease dumpster was open.-Cigarette butts all over the ground outside the back door.-Cardboard box with plastic and other garbage materials frozen to the ground outside the dumpster.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 65 residents (R).-Residents were not offered hand hygiene prior to meals.-Improper use of Personal Protective Equipment (PPE) by kitchen staff.-Staff did not wear gloves and/or gown during observation of wound care for resident R10.

Inspectors wroteBased on interview and record review, the facility did not ensure that a resident who requires dialysis receives such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 sampled resident (R52) reviewed for dialysis. The facility failed to provide ongoing assessments of R52's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. This is evidenced by:Facility's policy titled Hemodialysis with revised date of 09/10/23 documented in part, The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility.4. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure care and services were in accordance with professional standards of practice that will meet a resident's (R) physical, mental, and psychosocial needs for 1 of 8 residents. (R2)R2's call light was not kept within reach. R2 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease, aspiration pneumonia, weakness, dementia, stroke, larynx cancer, and gastrostomy. R2 is on palliative care. R2's care plan, with a revision date of 10/01/25, states R2 has a self-care deficit due to impaired vision, physical limitations, weakness, fatigue, Parkinson's disease, and pain. R2 requires assistance of one for toileting, transfers, and bed mobility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff providing care and services to residents (R) who have a feeding tube are competent in and utilize facility protocols/meeting professional standards regarding feeding tube care for 1 of 2 residents reviewed. Staff did not check placement prior to administering medications. Staff auscultated air to check placement prior to beginning tube feeding. R2's body was at a 20-degree angle while tube feeding was being administered. Facility policy dated 08/10/22, titled, Verifying Placement of Tube Feeding, states, in part, 1. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified. 2. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not provide a resident the needed supervision and assistance to eat safely per speech therapy recommendations. The facility practice affected 1 of 3 residents reviewed (R1). R1 has cancer of the larynx (throat) and a history of dysphagia (difficulty swallowing) and aspiration pneumonia. On 02/06/25, R1's speech therapy guidelines were not followed when R1 was not given assistance and supervision at mealtime. R1 choked on sweet potatoes. R1's POA, who had just come to visit, found R1 red in the face. No staff were present. R1's POA performed the Heimlich maneuver. The approach to be supervised while eating or drinking was not followed again as observed on survey 02/24/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not prepare, store, and distribute foods under sanitary conditions. The facility practice had the potential to affect all 61 residents. Floors in the kitchen, dish room and walk-in refrigerator/freezer had dirt and debris present during the initial tour of the kitchen. Carts used to transport foods and beverages to residents were discolored and had visible debris. Refrigerators in the ACU (Alzheimer's Care Unit) and East dining room, where resident foods are stored, had dried beverages and discolored ice pooled on the bottom. This is evidenced by: Example 1 The facility policy titled Food Preparation dated 9/2017. The policy in part read: Policy Statement All Foods are prepared in accordance with FDA (Food and Drug Administration) food code. Procedures 2. [...]

Inspectors wroteBased on record review and interview, the facility did not inform R1's power of attorney (POA) for health care when medication was initiated and dosage was changed. The facility practice affected 1 of 3 residents reviewed. R1 was started on Tramadol as needed and scheduled Tramadol was added without informing R1's power of attorney for health care of the risks and benefits of the medication. This is evidenced by: Surveyor requested and reviewed the facility policy titled Pain Management dated 8/09/2022. The policy in part read: Policy: This facility must ensure that pain management is provided to residents who require such services. consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. Pain Management and Treatment: [...]

Inspectors wroteBased on record review and interview, the facility continued administration of a psychotropic medication after the medication was no longer necessary and recommended to be discontinued. The facility practice affected 1 of 3 residents (R) R2, reviewed. This is evidenced by: Surveyor requested and reviewed the facility policy titled, Psychotropic Medications dated 10/24/2022. The policy, in part, read: Policy: Residents should not receive psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to the medication. Policy Explanation and Compliance Guidelines: 3. [...]

Inspectors wroteBased on observation, policy review and interview, the facility did not store foods brought in for residents and snacks for residents in a manner to prevent contamination in 2 refrigerators with the potential to affect 47 of 66 residents. This is evidenced by: Surveyor requested and received the facility policy titled Food From Approved Source most recently dated 9/2017. The policy in part read: ~Food may be brought into the facility by family, visitors or other outside sources. The facility staff will assist with proper food storage and handling as appropriate. Surveyor requested and received the facility policy titled Food Storage most recently dated 4/2018. The policy in part read: ~All foods will be stored wrapped or in covered containers, labeled, dated and arranged in a manner to prevent cross contamination. [...]

Inspectors wroteBased on interview and policy review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they have excessively low weekend staffing. This has the potential to affect all 66 residents residing in the facility. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. [...]

Inspectors wroteBased on interview and record review, the facility did not notify the resident and/or the resident's representative of resident transfer in writing including the reasons for the transfer. The facility did not give written notice of transfer or send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. The facility practice affected 5 of 5 residents reviewed (R49, R52, R6, R3 and R22).

Inspectors wroteBased on interview and record review, the facility did not provide notification of bedhold, including the resident right to appeal, to 4 of 5 residents and/or their representatives reviewed for hospital transfer (R52, R6, R3 and R22).

Inspectors wroteBased on interviews and record reviews, the facility did not consult with a physician as indicated by ordered parameters with a significant weight increase for 1 of 17 residents (R) R6. This is evidenced by: The facility policy titled Change in Condition of the Resident, dated September 2022, states in part, A facility should immediately consult with the resident's physician when there is the potential for requiring physician intervention; or a need to alter treatment significantly that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. R6 was admitted to facility on 05/25/18 and has diagnoses that include chronic obstructive pulmonary disease, hypertensive heart and chronic kidney disease with congestive heart failure (CHF). [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of verbal abuse was not reported immediately but not later than 2 hours after the allegation is made to local law enforcement in accordance with state law through established procedures. The facility practice affected 1 of 3 residents (R) reviewed. (R47). This is evidenced by: Surveyor requested and reviewed the facility policy titled, Reporting Reasonable Suspicion of a Crime which was last revised on 08/16/2022, which indicated the following: Policy: It is the policy of this center, pursuant to Section 1150B of the Social Security Act, to report any reasonable suspicion of a crime committed against a resident of this facility. [...]

Inspectors wroteBased on observation, policy review and interview, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 30 medication opportunities, resulting in an error rate of 6.67%. Surveyor had to intervene to stop Licensed Practical Nurse (LPN) C from administering eye drop to the wrong resident. This had the potential to affect 1 of 1 resident (R14) observed for medication administration. This is evidenced by: Facility policy titled, Medication Administration, stated in part, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record (MAR). [...]

Inspectors wroteBased on observation, record review and interview, 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 for 1 of 1 (R) resident observed for wound care while on Enhanced Barrier Precautions (R47), staff did not change gloves or perform hand hygiene during 1 of 5 observations (R6) of incontinence cares. This is evidenced by: Facility policy titled, Enhanced Barrier Precautions, with a most recent revised date of 08/08/24, stated in part: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from sexual abuse. This affected 2 of 6 residents reviewed for sexual abuse. (R1 and R6) On 02/19/24, R2 sexually abused R1 by groping R1 under the shirt and over the bra, touching R1's breast, while in a common area. After the incident, R2 was left unsupervised and 7 minutes later sexually abused R6, groping R6's breast over her shirt. After the first incident, appropriate interventions were not implemented to prevent the second occurrence of sexual abuse from happening. R1 and R6 were found to have severe cognitive impairment. This type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 15 residents (R) R36, reviewed for comprehensive care plans had a developed care plan specific to the resident. R36 did not have a care plan to include falls when R36 was at risk for falls and fell while in the facility. This was evidenced by: R36 was admitted to the facility on [DATE] and has diagnoses that include in part acute osteomyelitis to the left ankle, pressure ulcer of the left heel stage 4 (healed), unsteadiness on feet, congestive heart failure, anxiety, and dementia. R36's Minimum Data Set (MDS) assessment, dated 8/03/23, indicated that the Brief Interview for Mental Status (BIMS) score was 11 indicating moderate cognitive impairment. R36's transfer ability was extensive assist with 1-person physical assist. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff did not perform hand hygiene when warranted while providing care to one (R42) of three residents observed for care. Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted while providing morning cares to R42. This is evidenced by: On 10/31/23 at 7:23 AM, upon entering room, CNA C completed hand hygiene with soap and water. CNA C completed hand hygiene and donned gloves. CNA C wet washcloth and soap and gave to R42 to wash face. CNA C grabbed another washcloth, wet it, applied soap and began cares on upper body. Washcloth rinsed in basin and cleaned same areas. CNA C dried R42's face and upper body with clean towel and placed soiled washcloths in disposable garbage bags. CNA C removed gloves, did not complete hand hygiene and donned new gloves. [...]