West Oaks Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #27, Resident #50, and Resident #109) reviewed for resident rights. The facility failed to ensure CNA D knocked on Resident #27's door before entering the resident's room. The facility failed to ensure CNA E knocked on Resident #109's door before entering the resident's room. The facility failed to ensure Resident #50's catheter bag had a privacy cover on. These failures could place residents at risk of feeling like their privacy was invaded or cause psychosocial harm and emotional distress.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure residents had a right to organize and participate in resident groups in the facility for 10 of 10 confidential residents reviewed for resident council. The facility failed to provide the Resident Council with a private meeting area to conduct their monthly meetings. This failure could place residents at risk of not being able to exercise their rights to meet as a group in private.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 6 staff ( the DM, CK A and CK B) reviewed for food and nutrition services. The facility failed to ensure the DM, CK A and CK B wore appropriate hairnets so the hair was not exposed. This failure could place residents at risk of having hair in their food as well as ingesting contaminated food leading to illness. Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 6 staff ( the DM, CK A and CK B) reviewed for food and nutrition services. The facility failed to ensure the DM, CK A and CK B wore appropriate hairnets so the hair was not exposed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to 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 3 of 6 residents (Resident #50, #11, and #99) reviewed for infection control. The facility failed to ensure Resident #50 and Resident #11's catheter drainage bags were positioned correctly and not touching the floor on 02/23/2026 and 02/24/2026. The facility failed to ensure MA performed hand hygiene before preparing medications for Resident #99. The facility failed to ensure the Blood pressure monitor was sanitized after it was picked up from the floor and placed on the medication cart for Resident #99. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 5 residents (Resident #88 and Resident #91) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #91's annual MDS, dated [DATE], accurately reflected his smoking status. 2. The facility failed to ensure Resident #88's admission MDS, dated [DATE], accurately reflected her smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 6 residents (Resident #88) reviewed for care plans. The facility failed to ensure a comprehensive care plan was developed for Resident #88 to include her smoking status when the care plan was completed on 12/03/2025 and revised on 01/30/2026. This deficient practice could place residents at risk of not being provided with the necessary care or services and the implementation of personalized plan of care developed to address their specific needs.

Inspectors wroteBased on observation and interview the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 1 medication rooms reviewed for pharmacy services. The facility failed to ensure expired and/or discontinued medications removed from use for one medication storage room. This failure could place residents at risk of not receiving the intended therapeutic benefits of medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of eight residents reviewed for accidents and hazards. The facility failed to ensure Resident #1's wheelchair brakes were functional. This failure could place residents at risk for injury and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. 1. The facility failed to discontinue Resident #1's metformin and glyburide medications. 2. The facility failed to implement blood sugar monitoring for Resident #1. 3. The facility failed to start Resident #1 on the appetite stimulant (Mirtazapine) as ordered. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/10/2025 at 5:06 PM and an IJ template was given. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rights for personal privacy for 4 of 15 residents (Resident #23, Resident #52, Resident #78 and Resident #93) residents reviewed for personal privacy. The facility failed to knock on Resident #23, Resident #52, Resident #78 and Resident #93's room when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals in accordance with currently accepted practices for 1 of 4 (Cart #1,) medication carts reviewed for pharmacy services in that: Medication Cart #1 for the 100 hall was left unattended with the keys in the lock and was not locked. This deficient practice could affect residents and result in a drug diversion causing an allergic reaction or a resident taking medication not prescribed for them due to medications not being properly secured.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen and one of one nourishment room and one of one activities room reviewed for sanitation. 1. The facility failed to properly label and date perishable foods. 2. The facility failed to ensure the nourishment room was properly cleaned and items were correctly labeled and dated. 3. The facility failed to ensure employees did not wear jewelry and had removed false nails to best food service standards. 4. The facility failed to ensure employees were practicing proper hand hygiene while cooking and serving foods. 5. The facility failed to ensure meat was properly thawed under cold running water. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident (resident #93)with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents reviewed for dignity. 1. The facility failed to ensure Resident #93 received her lunch meal on 11/24/2024 in an adequate timeframe. This failure could place residents at risk of diminished dignity and affect their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 4 residents (Resident #69) reviewed for accidents and supervision. The facility failed to ensure Resident #69 was supervised while eating ice chips according to physician orders. This failure placed resident at risk for choking or aspiration due to lack of supervision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 2 residents (Resident #46) reviewed for indwelling catheter care. CNA G did not remove soiled gloves and conduct hand hygiene after cleansing Resident #46's perineal area, and cleansed the suprapubic catheter with a wipe x 2 during incontinent care. This failure could place residents at risk of the spread of diseases, a decreased quality of life, illness, and hospitalization.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 6 residents reviewed for comprehensive care plans. The facility failed to have a fall mat at Resident #1's bedside while he was lying in his bed. This deficient practice could place residents at risk of not receiving the care and services noted in their care plans.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #3 reviewed for pain management. The facility failed to ensure Resident #3 received his 08:00 AM scheduled Norco on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of increased pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #3 reviewed for medication administration. The facility failed to ensure Resident #3 received his 08:00 AM medications (Norco, Baclofen, Cozaar, and Cipro) on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of not receiving the therapeutic benefit of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to a dignified existence for 2 of 11 residents reviewed for dignity. 1. The facility failed to ensure that PTA A maintained Resident #1's dignity when speaking with her in a public area. 2. The facility failed to ensure Resident #2's back and incontinence brief area were not exposed in a public area while she waited for a shower. This failure placed residents at risk of embarrassment and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #2) of three residents reviewed for accidents and hazards, in that: The facility failed to ensure Resident #2 (who was a high-elopement risk) did not elope from the facility on 03/26/24 at 12:50 PM when the Receptionist used her remote-control door opener to unlock the front door. He was located over 24 hours later at a bus stop approximately 12 miles from the facility. The noncompliance was identified as PNC. The IJ began on 03/26/24 and ended on 03/27/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #1) out of three residents reviewed for ADLs, in that: The facility failed to provide showers to Resident #1 in compliance with his shower schedules. This deficient practice placed residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for transfer and discharge rights, in that: The facility failed to make arrangements for safe and orderly discharge through care planning completing a discharge summary for Resident #1, Resident #2, and Resident #3. This failure placed residents at risk of not receiving care and services to meet their needs upon discharge. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including congestive heart failure, hypertension (high blood pressure), type II diabetes, muscle wasting and atrophy (wasting away), dysphagia (difficulty with swallowing), and anxiety disorder. She was discharged from the facility on 11/01/23. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 4 residents (Resident #72) reviewed for accident hazards and supervision, in that; 1. Resident #72 had 2 unauthorized, unchaperoned elopement events on 10/03/2022 and 01/03/2023, without the facility providing adequate safety interventions to prevent further elopement risks. An IJ was identified on 09/01/2023. The IJ template was provided to the facility on [DATE] at 05:30 PM. [...]

Inspectors wroteBased on record reviews and interviews the facility failed to review and update their facility-wide assessment, as necessary, and at least annually. The facility assessment must address or include: The facility's resident population, including, but not limited to, both the number of residents and the facility's resident capacity and the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population for 4 of 4 (Resident #72, Resident #34, Resident #80, and Resident #141) residents and 1 of 1 facility's reviewed for elopement risks, in that; The facility assessment did not include any assessments for elopement care for the residents who were assessed as elopement risks. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to develop, within 7 days after completion of the comprehensive assessment, a comprehensive care plan, prepared by an interdisciplinary team, that includes but is not limited to; The attending physician, A registered nurse with responsibility for the Resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, the participation of the resident and the resident's representative(s), and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. The care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 8 residents (Resident #84) reviewed for care plans, in that: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible , for 2 out of 15 residents (Resident #32 and Resident #51) reviewed for indwelling catheters, in that; 1. The facility failed to ensure that Resident #32's indwelling catheter was secured to prevent pulling and/or tugging to the urethra. 2. Resident #51's catheter urine collection bag was held above the bladder during a transfer contrary to professional standards to prevent Catheter Associated Urinary Tract Infections [CAUTI]. These failures could place residents at risk for discomfort, urethral trauma (injury to the duct in which urine is transported out of the body from the bladder), and urinary tract infections.

Inspectors wroteBased on record review and interview the facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis, for 1 of 1 social services staff reviewed, in that: The facility, licensed for 125 beds, did not employ a full-time social worker. This failure could place residents at risk of social service and psychosocial needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 15 residents reviewed for call light: Resident #75 's call light was not placed within reach. This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed ensure the resident admitted to the facility had an accurate pre-admission PASRR Level I screening before admission and to incorporate the recommendations and submit a complete and accurate request for nursing facility specialized services in LTC Online Portal for 1 of 5 (Resident #87) residents reviewed for Pre-admission Screening and Resident Review (PASRR) in that: 1. Resident #87 did not have an accurate PASRR Level I completed prior to admission. 2. Resident #87's IDT meeting was not completed as required. 3. Resident 87's PASRR Level II was not completed and sent to LMHA (Local Mental Health Authority) within the 20 business days as required. 4. Resident # 87's PASRR Level I per the MDS Coordinator and the diagnoses did not accurately reflect how long it took for the facility to identify the incorrect PASRR Level i. [...]

Inspectors wroteBased on observation and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 15 (Resident #65) residents reviewed, in that: 1 . Resident #65's Foley catheter was removed on 7/10/2023, and the order for catheter care was not discontinued This failure could result in inadequate care due to incomplete and inaccurate medical records.