Oak Knoll Health And Rehabilitation, LLC

Based on record review, interview, review of an Online Incident Report and review of facility policy Abuse, Neglect Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure Resident Identifier RI #1 was not talked to in a demeaning way by a Certified Nursing Assistant (CNA) #4. This incident occurred on 1/28/24 and affected RI #1. This was cited as a result of investigation of complaint/report number AL00046804 and affected RI #1, one of one resident verbally abused. Findings include: Review of a facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of 10/15/2022 documented . Verbal- Verbal abuse is the use of oral, written or gestured communication or sounds that includes disparaging and derogatory terms to resident/guest(s) or their families/representatives . Review of a facility Online Reported Incident dated 01/28/2024 documented . 05:30 AM CNA #4 cursed out Resident (RI)#1 over a cigarette lighter. RI #1 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and a review of a facility policy, Supervised Smokers, the facility failed to ensure Resident Identifier (RI) #1 was not found with a lighter in his possession on two separate occasions. This affected RI #1, one of 13 residents listed as a smoker. This was cited as a result of investigation of complaint/report number AL00047459. Findings Include: Review of a facility policy Supervised Smokers with an effective date of 10/15/2022 documented . PROCESS: . 2. Smoking materials should be kept at the nurse's station, and . 3. No fire igniting materials (matches/lighters) should be kept in resident/guest(s) possession. Smokers should obtain lighting materials from staff. On 5/1/24 at 3:50 PM during an interview with Registered Nurse (RN) #3, she said she recalled RI #1 and CNA #4 arguing over a lighter. RN #3 said she never saw the lighter. RN #3 said RI #1 said he/she found the lighter in his/her shoe. RN #3 went to the room to get the lighter and RI #1 said he/she did not have a lighter and was not going to give it to her. RN #3 said she was first aware…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, interviews and review of facility policy, the facility failed to store, prepare, and distribute food in a sanitary manner for two (2) of three (3) days of the survey. This deficient practice has the ability to affect all residents that received food or beverage from the facility's kitchen. Findings include: Interview with the Dietary [NAME] on 3/16/21 at 10:00 a.m. revealed the Certified Dietary Manager (CDM) was not in the facility at this time. Observation during the initial tour of the kitchen on 3/16/21 from 10:00 a.m. to 10:30 a.m. revealed: -Dirt and leaves on the floor by the walk-in cooler, walk-in freezer, and dry storage area -A five (5) pound container of peanut butter opened and not labeled with the date when opened -Two (2) cans of blueberries with dents along the edges of the can on a shelf with other cans of blueberries -A bag of sliced cheese in the walk-in refrigerator opened to the air -Ice build-up in the walk-in freezer around the light and switch covering -Can opener with accumulated colored debris on the cutting blade…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview and review of facility policy, the facility failed to follow the menus. Specifically, the facility failed to follow the recipes for the pureed menu items, failed to follow the menu for pureed corn bread, and failed to adhere to the appropriate serving size of the bread for 12 of 12 residents that received pureed diets (Resident #5, Resident #6, Resident #22, Resident #23, Resident #25, Resident #27, Resident #30, Resident #31, Resident #36, Resident #78, Resident #139, and Resident #140). Findings include: Interview on 3/17/21 at 10:55 a.m. revealed the Dietary [NAME] stated he/she would make 16 servings of the pureed menu items. There were 12 residents who received pureed diets. Review of the Physician Orders List for diets revealed 12 residents had orders for pureed diets (Resident #5, Resident #6, Resident #22, Resident #23, Resident #25, Resident #27, Resident #30, Resident #31, Resident #36, Resident #78, Resident #139, and Resident #140). Observation on 3/17/21 beginning at 10:55 a.m. revealed the Dietary [NAME] removed a steam…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interviews the facility failed to develop and implement a comprehensive care plan for one (1) of two (2) residents that received dialysis services (Resident #66). The facility failed to implement the care plan regarding obtaining information from the dialysis center and failed to assess the fluid intake for Resident #66 who was on a fluid restriction. Findings include: Review of Resident #66's clinical record revealed a readmission date of 1/25/21; diagnoses included: Paranoid Schizophrenia; End Stage Renal Disease (ESRD); and Renal Osteodystrophy (complication of ESRD leading to skeletal and extraskeletal manifestations). Review of Resident's #66 Care Plan dated 1/25/21 for Fluid Restriction included the following interventions: assess intake and output (I&O) and obtain weight and labs from the dialysis center. Review of the Physician's Orders for 3/2021 included an order for a 1200 cubic centimeter (cc) fluid restriction with dietary to provide 720 cc, first shift to provide 240 cc, second shift to provide 120 cc and third shift to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure ongoing communication between the facility and the dialysis center for two (2) of two (2) sampled residents (Resident #66 and Resident #86) reviewed for dialysis. In addition, the facility failed to complete intake and output records per Physician's Orders for Resident #66 who had a fluid restriction in place and failed to follow-up on the dialysis center Dietician's recommendation for Novosource (nutritional supplement). Findings include: 1. Review of Resident #66's clinical record revealed a readmission date of 1/25/21; the resident's diagnoses included: Paranoid Schizophrenia, End Stage Renal Disease (ESRD), and Renal Osteodystrophy (complication of ESRD leading to skeletal and extraskeletal manifestations). Review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview, and policy review the facility failed to ensure that medications were stored properly in one of two medication carts surveyed. One blister pack card of expired medication was found in Medication Cart #2. Findings include: A medication card of Oxycodone Hydrochloride (narcotic pain medication) five (5) milligrams (mg) with expiration date of [DATE] was found in the narcotics drawer of Medication Cart #2 during the medication cart inspection on [DATE] at 9:45 a.m. The Narcotics Log Sheets from [DATE] admission to [DATE] and resident's medical record reflected that the medication had an active order for the medication of one half (½) tablet by mouth PRN (as needed) every four (4) hours. Review of the 3/2021 Medication Administration Record (MAR) and 2/2021 Physician's Orders reflected that Oxycodone Hydrochloride was prescribed for Resident #55 who was readmitted to the facility on [DATE] after an acute hospital stay. The medication was prescribed on [DATE] for pain on an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of facility policy, two (2) staff failed to wear all required personal protective equipment (PPE) when entering two (2) residents' isolation rooms during meal-service (Resident #139 and Resident #140). Findings include: Observation on 3/16/21 at 1:18 p.m. revealed Certified Nurse Aide (CNA) #2, who was wearing gloves but no other personal protective equipment (PPE), provided the disposable lunch tray to Resident #140 in his/her room. CNA #2 placed the tray on the overbed table, moved the overbed table to the opposite side of the bed, and set-up the tray for the resident to eat. Further observation at that time revealed two (2) signs on the door from the hallway into the room. One sign identified the resident was on droplet precautions and the second sign identified the resident was on contact isolation. Review of the clinical record revealed Resident #140 was admitted on [DATE]: the diagnoses included Orthopedic Aftercare and Schizoaffective Disorder. Observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of the Potter / [NAME] Fundamentals of Nursing Ninth Edition, the facility failed to ensure licensed staff did not leave medications unattended at Resident Identifier (RI) #17's bedside while she left the resident's room for needed supplies. This affected one of six residents observed for medication pass and one of four nurses observed for medication pass. Findings Include: A review of the Potter/[NAME] Fundamentals of Nursing Ninth Edition Chapter 32 Unit V Foundations for Nursing Practice Administering Oral Medications . Implementation . page 657 revealed: . l. Do not leave medications unattended. Nurse is responsible for safekeeping of drugs. RI #17 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Diabetes Mellitus, Hypertension, Kidney Transplant Status, Pain and Chronic Pulmonary Edema. A review of RI #17's February 2019 Physician Orders revealed . Novolog . 20 UNITS THREE TIMES WITH MEALS . METOPROLOL TARTRATE 25 MG . GIVE 1/2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, a review of a facility's policy titled, Incidents and Accidents, and a review of a facility document titled, Resident Incident Report, the facility failed to ensure Resident Identifier (RI) #38's bed was locked during peri-care on 08/23/17. RI #38 fell out of the bed which resulted in RI #38 being transported out of the facility for emergency treatment for a contusion to the left forehead. This affected one of two sampled residents reviewed for falls. Findings Include: A review of the facility's policy titled, Incident and Accidents, with an effective date of August 26, 2013, revealed: PURPOSE: The resident environment remains as free of accident hazards as is possible . RI #38 was admitted to the facility on [DATE] with diagnoses of Cerebrovascular Disease, and Vascular Dementia without Behavioral Disturbance. RI #38's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/14/2017, revealed RI #38 was assessed as requiring total assistance with bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interviews, a review of the facility's policy titled, Bowel and Bladder Program,and a review of Resident Identifier's (RI) #99's Care Plan, the facility failed to ensure RI #99 was toileted upon request to maintain bladder function. This affected one of seven residents reviewed for bowel and bladder function. Findings Include: A review of the Facility's policy titled,Bowel and Bladder Program, with an effective date of October 1, 2010 revealed: . PURPOSE: A resident who is incontinent of bowel and bladder receives appropriate treatment & (and) services to prevent urinary tract infections & to restore as much normal bowel/bladder function as possible. STANDARD: Each resident who is incontinent of urine/bowel is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary/bowel function as possible . PROCESS: 1. A Bowel and Bladder Review should be conducted at admission, with a change in cognition, physical ability or urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, medical record review, a review of a facility's policy titled, Dentures-Cleaning and Storing, and [NAME] AND PERRY'S, FUNDAMENTALS OF NURSING, the facility failed to ensure RI (Resident Indentifer) #30's dentures were not soaking in a dirty, discolored solution containing debris and sediment. This was observed on two of three days of the survey. This deficient practice affected RI #30 one of twenty five sample residents. Findings Include: A review of a facility's policy titled, Dentures-Cleaning and Storing, with an effective date of October 1, 2010 revealed: .PURPOSE: Clean dentures help to freshen and clean the resident's mouth and lessen the potential for infections of the mouth. A review of [NAME] AND PERRY'S, FUNDAMENTAL OF NURSING, NINTH EDITION, CHAPTER 40, page 841 revealed: . Denture Care. Encourage patients to clean their dentures on a regular basis to avoid gingival infection and irritation. When patients become disabled, someone else assumes responsibility for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.