West Oaks Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinence. The facility failed to ensure Resident #1 did not have feces in her private area after she was provided incontinent care on 07/29/26 from 3:29 p.m. through 3:41 p.m. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible and receives adequate supervision to prevent accidents for 1 of 2 (Resident #24) residents reviewed for accident hazards.-The facility failed to ensure Resident #24 was transferred with a one-person assist when she was a two-person assist on 3/3/2026 and sustained an injury requiring stitches. This failure could place residents at risk of injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food to be used later with a temperature in the danger zone was discarded. 2. The facility failed to ensure leftover food past the due date was discarded.3. The facility failed to ensure that food past the use date was discarded. 4. The facility failed to ensure food was stored 6 inches off the floor.5. The facility failed to store in a separate container a scoop used for food bins in the kitchen storeroom.6. The facility failed to fix broken tiles in the kitchen These failures could place residents at risk of food borne illness and disease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with incontinent bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 18 resident (Resident #8) reviewed for incontinent care. The facility failed to ensure CNA A put on a gown and changed gloves and cleaned Resident #8's indwelling catheter and penis foreskin before putting on a clean brief during foley catheter and incontinent care on 3/12/26. This failure could place residents at risk for pain, infection, injury, and hospitalization. Record review of Resident #8's face sheet, dated 3/10/2025, revealed an [AGE] year-old male admitted [DATE] and re-admitted [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feedings including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1 of 5 residents (Resident #108) reviewed for feeding tubes. The facility staff failed to check Resident #108's g-tube placement before administering medication on 3/10/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 2 of 11 residents (Resident #8 and Resident #108) reviewed for infection control. 1. The facility failed to ensure CNA A used the required PPE (gown) for Resident #8, who was on enhanced barrier precautions while performing incontinent/indwelling foley catheter care on 3/10/26. 2. CNA A failed to perform hand hygiene with glove changes during perineal care on Resident #8 3, RN H poured iron supplement liquid into a medication cup and then poured it back into the original 6 fl oz bottle, which could cause contamination, on 3/10/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 18 residents (Resident #89, Resident #310) who were observed for call light placement. The facility failed to ensure that call light were within reach for Resident #89 and Resident #310. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #6 and Resident #55) reviewed. -The facility failed to ensure that Resident #6's status of anticoagulants was a focus area in the resident's comprehensive care plan and no intervention was in place. -The facility failed to ensure that Resident #6's status of oxygen was a focus area in the resident's comprehensive care plan and no intervention was in place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menus for pureed meals (lunch meal on 01/15/2025) reviewed for menus in that: The facility failed to follow the recipe for pureed diets meals prepared for the lunch meal on 01/15/2025. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Residents #8) reviewed for accidents. -The facility failed to ensure Resident #8 had two fall mats in his room according to his comprehensive care plan. -The facility failed to ensure Resident #8's Physician Orders for two fall mats with a start date of 1/10/2025 were added as interventions in his comprehensive care-plan. Record review of Resident #8's facility admission record revealed that Resident #8 was an [AGE] year-old male admitted on [DATE]. Resident #8's diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders for 1 (Resident #38) of 8 residents reviewed for infection control. -The NF failed to change Resident #38's midline IV (a Thin flexible tube inserted into a vein in the upper arm) dressing weekly as ordered by the physician on 1/13/25. This failure placed residents at risk for infections and decrease in quality of life.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that residents needing respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centereed care plan for 1 of 2 residents (Resident #55) reviewed for oxygen therapy. --The facility failed to ensure Resident #55 had continuous oxygen according to Physician Orders when she was found without her oxygen cannula on 1/15/2025 at 11:35am. This deficient practice could affect residents getting medically required treatment and lead to a decline in health.

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 (Resident #31) of 5 residents observed for medication administration. -The facility failed to administer Resident #31's medications Furosemide and Gabapentin at the scheduled time set by the NF, 8:00AM. This failure placed residents at risk of unwanted drug interactions and decrease in quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: The dish washing and sanitizing machine's water temperature and sanitizer levels were below the manufacturer's required minimum wash and rise temperatures and levels. These deficient practices could place residents who received meals from the main kitchen and place them at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 9 % based on 3 errors out of 33 opportunities, which involved 2 of 8 residents (Resident #90 and Resident #99) reviewed for medication errors. MA A failed to give Resident #90 her Metoprolol (blood pressure medication) and Trazadone (antidepressant medication) as directed by pharmacy, which was with or immediately after meals. MA A failed to give Resident #99 his Fenofibrate (high cholesterol medication) as directed by pharmacy, which was with a meal. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled health conditions.