West Oaks Nursing & Rehabilitation

Based 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.During an observation of the facility kitchen on 03/10/26 at 8:00 a.m., it revealed the following: 1. Can opener blade with food debris.2. An open package of deli ham with no used by date in the fridge.3. A package of sliced swiss cheese not dated, no used by date in the…

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 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]. His medical diagnoses included muscle wasting and atrophy ( loss of muscle tissue, causing muscles to become small, thinner and weaker) not elsewhere classified, unspecified shoulder, dysphagia ( difficulty swallowing), oropharyngeal phase(difficulty initiating a…

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 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. This failure could place residents at risk for complications such as aspiration pneumonia (occurs when food or liquid is breathed into the airway or lungs, instead of being swallowed), pneumothorax (a condition that occurs when air leaks into the space between the lungs and chest wall), perforations, empyema (one of the diseases that compromises chronic obstructive pulmonary disease), bronchopleural fistula (a sinus tract between the main stem,…

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 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. These failures could place the residents at risk of cross-contamination and development of infection. Record review of Resident #108's face sheet, dated 3/10/26, revealed a [AGE] year-old male was…

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 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. Findings included: 1. Record review of Resident #89's face sheet captured on 01/16/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE]. His medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right-sided weakness after a stroke), essential hypertension (high blood pressure), Schizophrenia (a serious mental health condition characterized by hallucinations, delusions and unorganized thinking), Bipolar Disorder(a serious mental health…

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 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. -The facility failed to ensure Resident #55's status of oxygen was a focus area in the resident's comprehensive care plan. These deficient practices could affect residents by contributing to inadequate…

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, 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. The findings included: In an observation/interview on 01/15/2025 at 11:26 a.m., approximately 24-pieases of 4 ounce (oz) baked tilapia on a tray in the oven. [NAME] removed 7-pieces of tilapia from the tray and placed them into the mechanical blender along with 7 pieces of bread, and broth. The [NAME] stated that she was unsure exactly how many residents required pureed diets. She then asked the interim dietary manager (IDM) who had replied that there were 10-residents eating in the dining room and another 6-residents eating in their rooms. When asked how many pieces of fish the [NAME] had blended for those residents, she stated she added 15-pieces of fish to cover the…

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 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: chronic heart failure, vascular dementia (a type of dementia caused by brain damage from impaired blood flow), chronic kidney disease, cardiomegaly (enlarged heart), hyperlipidemia (high fat content in the blood), hypothyroidism (low levels of the hormone thyroid which regulates the body's functions like the metabolism), Type 2 Diabetes…

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 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. Findings: Record review of Resident #38's face sheet dated 01/16/25 revealed a [AGE] year-old male admitted to the NF on 05/07/24. Resident diagnoses included the following: pulmonary embolism (one or more arteries in the lungs become blocked by a blood clot) , hemiplegia (complete paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the of the body that can affect the arms, legs and facial muscles), Type 2 diabetes mellitus (when the body…

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, 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. Findings include: An interview with the DON on 1/15/25 at 11:35am, she said she will have to check if Resident #55 required oxygen and will provide an update. She said the care plans for oxygen should have been there if there was an order. The DON said that the facility had 48-hours to update the plan. The DON also said Resident #55 had an order for oxygen and it should have been on the care-plan, but that she talked with the…

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 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. Finding: Record review of Resident #31's face sheet dated 01/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident diagnoses included the following: heart disease, dementia (impairment of at least two brain functions that includes memory loss and judgement), peripheral artery disease (a condition in which narrow blood vessels reduce blood flow to the extremities), hypertension (elevated blood pressure), and chronic…

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, 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. Findings include: Interview and observations on 11/28/2023 at 7:37 AM with Dietary Manager The dishwasher displayed was a low temperature washer. The Dietary Manager agreed the water temperature was low. The water measured 110 degrees F and the sanitizer was measured three times and indicated the sanitizer levels were 25, 25, and 25 PPM . She said she typically worked 6:30 AM- 3:30 PM Monday through Friday. She said she had worked at the facility for 4 years and worked in…

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 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. Findings include: Resident #90 Record review of Resident #90's Face Sheet dated 11/29/2023 revealed, a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: senile…

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.