Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakcrest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple neurocognitive and psychiatric diagnoses, who required assistance with personal hygiene, was found non-interviewable in his room with a urinal on the bedside table containing dark yellow urine and surrounded by numerous small bugs, while the urinal itself appeared stained and corroded. A CNA reported last entering the room earlier that morning, acknowledged the presence of many bugs around the urinal, and noted the room’s toilet was not working, requiring the urinal to be emptied elsewhere. The resident’s privacy curtains were visibly soiled with a brown substance and described by staff as “nasty,” and the Maintenance Director, responsible for monitoring pests and environmental issues, had not been in the room that day but later identified the bugs as gnats and stated the curtains looked dirty and should have been changed. Separately, surveyors observed peeled and raised laminate flooring in an east hallway, which another resident said had been peeled by a resident, while the Maintenance Director stated the flooring would be repaired later and that no trips had been reported, despite facility policies requiring a clean, well-maintained environment and safe, decent, clean conditions for residents.
A resident with intact cognition and documented diagnoses of dementia, bipolar disorder, and schizoaffective disorder, as well as a known history of rape and head injuries, did not have her trauma history, delusional behavior, or major psychiatric diagnoses fully incorporated into her comprehensive care plan. Initial care plan review showed no mention of sexual trauma, delusions, schizophrenia, or bipolar disorder, and a later revision added only that she was a victim of physical abuse with general safety-related interventions, still omitting specific interventions for delusions and psychiatric conditions. The SW had long been aware of the resident’s assault history and persistent schizophrenia and delusions, and the psychologist’s documentation and progress notes described trauma-related experiences and increased manic behavior, but the DON, who was responsible for clinical care plan updates and did not perform a clinical background check, did not ensure these needs were reflected in the care plan, contrary to facility policy requiring a comprehensive, person-centered care plan including social services.
Infection Control Lapses During Food Preparation: The DS failed to maintain infection control during meal prep by not washing hands between pureed food items, using the same alcohol swab to clean a thermometer between food items, and touching a lid with the thermometer before continuing temperature checks. The DS, DON, and ADM all described kitchen hand hygiene and thermometer sanitation expectations, and the ADM stated that using the thermometer to pick up lids without sanitizing it first was an infection control issue.
Care Plans Missing Dementia and Alzheimer’s Focus Areas: A review of 3 residents with dementia or Alzheimer’s diagnoses found that their care plans did not include specific focus areas or goals for those conditions. The MDS records for each resident also lacked a BIMS score, and interviews with CNA, LVN, DON, and ADM confirmed that dementia/Alzheimer’s should be documented in the care plan so staff can provide individualized care.
Failure to document controlled medication administration occurred when an LPN administered Tramadol, Ativan, and Lorazepam to several residents without signing the narcotic count sheets at the time of removal, and later gave Tramadol via G-tube to another resident without completing the controlled-substance documentation. Another LPN stated she had prepared controlled meds for the resident but had not yet signed the narcotic count sheets, while the DON stated controlled substances should be signed out right after removal and that medication bottles and packages should be dated when opened.
Opened medications and biologicals were not properly labeled in 1 med room and 1 med cart. During observation, an opened Med Pass 2.0+ supplement was found in a med cart not on ice and not dated properly, and in a med room three opened OTC meds—Pepto Bismol, Geri-Lanta, and MiraLAX—had no open dates. The DON and LVN stated opened bottles and supplements should be dated when opened, with supplements kept on ice and OTC bottles discarded within 30 days.
Infection Control Failures During Resident Care Tasks: An LPN used alcohol-free wipes for hand cleansing during blood glucose checks, a CNA did not perform hand hygiene or glove changes while providing peri-care and moved between clean and dirty areas without proper technique, and an LPN did not don the required gown or mask before wound care for a resident on EBP. The affected residents had diagnoses including diabetes, incontinence, dementia, Huntington's disease, and a wound requiring treatment.
Worn Bedroom Walls Did Not Support a Homelike Environment: Two residents shared a bedroom with scratched up and torn walls next to both beds. One resident with no cognitive impairment said the room had looked that way since before he arrived and did not feel homelike, making him feel like he lived in a facility rather than a home. Staff, including CNA, LVN, MS, DON, and ADM, acknowledged the walls were not homelike and said the MS was responsible for repairs.
Medication administration errors caused the facility’s error rate to exceed the allowed threshold for a resident with DM2, vascular dementia, and severe cognitive impairment. An LPN administered insulin without checking the physician order parameters and relied only on the label, and a CMA failed to give two ordered daily medications, Ferrous Sulfate and Cholecalciferol, while still documenting them on the MAR.
Call Light Not Within Resident Reach: A resident with Type II DM, schizophrenia, and muscle weakness did not have his own call light next to his bed during observation, while his roommate did. The resident stated he had not had his own call button since admission and did not know how he would call for help. Staff and leadership stated call lights are important for resident safety and access to help, and the facility policy required call lights to be within residents' reach and checked for function.
A facility failed to update care plans for residents, leading to significant deficiencies. A resident with dysphagia was not identified as a choking risk in their care plan, resulting in a fatal choking incident. Another resident's refusal of ADL care was not addressed in their care plan, and a third resident's challenging behaviors were not documented, leaving staff without guidance. Additionally, two residents' smoking habits were not reflected in their care plans, potentially impacting their care.
A resident with multiple diagnoses, including dementia and Alzheimer's, choked and died during a meal due to inadequate supervision and failure to update care plans with necessary interventions. Despite being diagnosed with oropharyngeal dysphagia, the resident's care plan did not reflect the need for assistance with feeding. Staff were unaware of the resident's swallowing difficulties, and there was no clear communication or documentation of dietary requirements and risk factors.
A resident with a history of swallowing difficulties choked and died, but the incident was not reported to the State agency as required. The facility staff, including the DON and ADM, were uncertain about the need to report the incident, and no investigation was conducted. Interviews revealed inconsistencies in the understanding of the resident's condition and lack of communication regarding the resident's care plan.
A facility failed to properly administer medication to a resident with multiple diagnoses, including Alzheimer's and schizophrenia. A pill was found on the floor of the resident's room, identified as Depakote, which should have been administered by the night MA. The DON and ADM emphasized the importance of ensuring medications are swallowed and not left unsupervised, as per the facility's policy.
A resident with a history of mental illness and other medical conditions walked out of the facility unattended due to inadequate supervision. The night nurse did not physically check on the resident, leading to an unnoticed elopement. The facility's policy required physical checks every two hours, but this was not followed.
Failure to Maintain Clean Resident Room and Safe Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a safe, clean, comfortable, and homelike environment for a male resident with dementia, bipolar disorder, schizophrenia, stroke history, type 2 diabetes, major depressive disorder, Alzheimer's disease, and dysphagia. His MDS showed he required setup or clean-up assistance with personal hygiene and his care plan noted risk for increased confusion and decline in ADLs as his disease progressed. On observation, the resident was non-interviewable and seated in his wheelchair in his room with a urinal on the table in front of him that was about one third full of dark yellow urine. There were approximately 25 small bugs visible on and around the urinal and an upside-down foam cup, and the urinal appeared stained and the plastic corroded. A CNA reported that the last time he had been in the resident’s room was around 9:00 AM that day and that the resident liked to empty his own urinal and sometimes refused to have it emptied, but that morning he did not refuse. The CNA stated the toilet in the resident’s room was not working, so he had to empty the urinal elsewhere. During this same observation, the resident’s curtains were noted to be stained with a brown substance, and the CNA described the curtains as “nasty” and acknowledged there were a lot of bugs around the urinal. The Maintenance Director, who stated it was his responsibility to monitor for pests and to be notified of pest issues, had not entered the resident’s room that day. After viewing a photo of the urinal, he identified the bugs as gnats and estimated, based on their number, that the urine had likely been sitting for two days. He also stated that staff were supposed to notify him or housekeeping when curtains needed to be removed for cleaning and agreed the curtains looked dirty and should have been changed. In addition to the conditions in the resident’s room, surveyors observed environmental deficiencies in the facility’s east hallway, where laminate floor paneling was peeled off and raised. Another resident reported that a resident had peeled off the floor. The Maintenance Director stated the damaged flooring would be repaired the following week and that, to his knowledge, no residents had tripped over it. The DON stated that pest control services occurred every two weeks and that it was everyone’s responsibility to monitor resident rooms for pests, but he had not been in this resident’s room that morning and stated he did not know how residents could be affected by pests. The Administrator reported that the facility had policies for maintenance, housekeeping, and resident rights for a homelike environment, that everyone was responsible for monitoring and reporting environmental concerns, and that he assumed urinals were emptied once a day. Facility policies reviewed stated that the residence would be kept clean and well-maintained through regular cleaning and preventive maintenance, and that residents had the right to safe, decent, and clean conditions.
Failure to Incorporate Trauma History and Psychiatric Diagnoses Into Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that incorporated a resident’s known psychiatric diagnoses and trauma history. Record review showed that the resident, an adult female with intact cognition (BIMS score of 15), had documented diagnoses including cognitive communication deficit, restlessness and agitation, unspecified dementia, bipolar disorder, and schizoaffective disorder. A psychologist’s clinical treatment plan documented that she had experienced rape and head injuries while living with others and on the street. Progress notes reflected increased manic behavior and a claim of an alleged rape occurrence. Despite this, review of the resident’s care plan on consecutive days showed that it initially contained no mention of her history of sexual trauma, delusional behavior, or diagnoses of schizophrenia and bipolar disorder. When the care plan was revised, it was updated only to reflect that the resident was a victim of physical abuse, with interventions focused on providing a safe environment, establishing safety and trust, discussing safe and healthy relationship skills, and providing referrals and resources. There continued to be no care plan interventions addressing her delusional behavior or her schizophrenia and bipolar disorder. Interviews with the DON, Administrator, and SW revealed that the DON and nursing staff were responsible for revising care plans, that the DON did not conduct a clinical background check when updating care plans, and that the SW had long been aware of the resident’s sexual assault history and persistent schizophrenia and delusions but did not revise care plans. The facility’s own care planning policy required development of a comprehensive, person-centered care plan based on individual assessed needs, including social services, yet the resident’s documented trauma history and psychiatric conditions were not fully incorporated into her comprehensive care plan. The Administrator acknowledged that nursing should know about the resident’s history and that not having an updated care plan created potential for a negative outcome if important information was missed.
Infection Control Lapses During Food Preparation
Penalty
Summary
The facility failed to maintain infection control practices during food preparation for 1 of 1 meal preparation observations. During an observation on 08/06/2025 at 11:25 AM, the DS pureed lunch items and placed chicken into the puree blender, completed the puree process, emptied the chicken from the blender, and then continued to puree three additional menu items without washing hands in between food items. During a separate observation on 08/06/2025 at 11:45 AM, the DS took temperatures of food items using a thermometer and an alcohol swab, but used the same alcohol swab to clean the thermometer after each food item. The DS then used the same thermometer to pick up a lid and continued temperature checks without sanitizing the thermometer first. After the temperature checks, the DS completed hand washing by turning on the water, using soap, and then turning off the sink with a hand before drying hands with a paper towel. In interviews, the DS stated that hand hygiene should include turning off the sink with a paper towel and that hands should be washed in between food items depending on the meat. The DS also stated that the thermometer should be cleaned with an alcohol swab between menu items and that using the same alcohol swab every time could result in cross contamination. The DON and ADM both confirmed expectations for hand hygiene and thermometer sanitation in the kitchen, and the ADM stated that staff should not use the thermometer to pick up lids and continue temperature checks without sanitizing it first.
Care Plans Missing Dementia and Alzheimer’s Focus Areas
Penalty
Summary
The facility failed to establish person-centered care plans for 3 of 3 residents reviewed for care plans: Resident #52, Resident #7, and Resident #35. Each resident had diagnoses involving dementia or Alzheimer’s disease, but the care plans did not include a focus area and goal for those diagnoses. The facility’s policy titled Care Planning, dated 12/13/2020, stated that a comprehensive person-centered care plan should be developed for each resident based on individual assessed needs and should include measurable objectives and a timetable to meet the resident’s medical, nursing, mental, and psychosocial needs. Resident #52’s record showed diagnoses including Alzheimer’s disease, cognitive deficit disorder, and generalized anxiety disorder. His care plan, last updated 06/14/2025, reflected Alzheimer’s disease but did not include a focus area and goal for that diagnosis. His annual MDS dated 04/19/2025 did not reflect a BIMS score and noted memory problems and severely impaired cognitive skill. Resident #7’s record showed diagnoses including dementia, Alzheimer’s disease, major depressive disorder, schizophrenia, urinary tract infection, chronic pain, and cerebral infarction. His quarterly MDS did not reflect a BIMS score and noted dementia and Alzheimer’s disease. His care plan, last revised on 07/18/25, reflected dementia but did not include a focus area for dementia or Alzheimer’s disease. Resident #35’s record showed diagnoses including alcohol-induced dementia, cognitive communication deficit, need for assistance with personal care, and muscle weakness. His quarterly MDS did not reflect a BIMS score and noted non-Alzheimer’s dementia and anxiety disorder. His care plan, last revised on 06/26/25, reflected alcohol dependence with alcohol-induced persisting dementia but did not include a focus area for dementia or Alzheimer’s disease. Interviews with CNA A, LVN D, the DON, and the ADM confirmed that dementia/Alzheimer’s should be documented in the care plan so staff can provide proper, individualized care.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not documenting the administration of controlled medications on the narcotic count sheets for 5 of 7 residents reviewed for pharmaceutical services: Resident #50, Resident #24, Resident #20, Resident #35, and Resident #11. During medication administration observation, LVN C was seen administering controlled substances to Resident #50, Resident #24, Resident #20, and Resident #35 without signing the narcotic count sheets at the time the medications were removed. The medications observed included Tramadol 50 mg for pain, Ativan 0.5 mg for anxiety, and Lorazepam 1 mg for anxiety. During a later observation of gastrostomy tube medication administration for Resident #11, LVN C again did not sign out the controlled substance on the narcotic sheet after administering Tramadol 50 mg per tube for pain. LVN E stated she had prepared Tramadol, Gabapentin, and carbidopa-Levodopa for Resident #11 but had not yet signed the narcotic count sheets, and acknowledged she was supposed to sign them right after removing the controlled medications. The DON stated controlled substances should be signed out after removal and that medication bottles and packages should be labeled and dated when opened; the facility's medication administration policy required documentation of all medications administered in the MAR.
Improper Labeling and Dating of Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates, in 1 of 2 medication rooms and 1 of 3 medication carts reviewed. During an observation of medication administration with CMA A, a supplement drink, Med Pass 2.0+, was found opened, dated, and not on ice inside medication cart A. CMA A stated he had not left the supplement in the cart and said supplements or puddings used during medication administration should be dated when opened and kept on ice for food safety purposes, otherwise it could make residents sick. In medication room E, three over-the-counter medications that were used for multiple residents per physician orders—Pepto Bismol, Geri-Lanta, and MiraLAX—were observed opened with no date showing when they were opened. LVN E stated nursing was supposed to write the date the bottle had been opened and that the medications were poured into a medication cup and then administered to the resident. The DON stated the charge nurse and DON were responsible for ensuring opened medication bottles and other packages were labeled and dated, and that opened OTC bottles should be dated when opened and disposed of within 30 days. The facility's Medication Storage Protocol required multiple-dose medications and other items to be marked with the date opened or first used, and the medication cart to be checked monthly to ensure medications were in date and properly dated.
Infection Control Failures During Blood Glucose Checks, Peri-Care, and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 5 of 7 residents reviewed for infection control. During observation of blood glucose checks for Resident #2 and Resident #46, LVN E cleansed her hands with alcohol-free adult washcloths before and after the procedures, and then used an alcohol pad to clean the glucometer. Resident #2 was a male resident with diagnoses including diabetes mellitus type 2, immunodeficiency, hyperlipidemia, chronic pain, hypertension, difficulty walking, and cognitive communication deficit. Resident #46 was a male resident with diagnoses including diabetes mellitus type 2, chronic kidney disease, hypertension, and urinary retention, and had an order for sliding-scale insulin before meals and at bedtime. During peri-care observations, CNA B did not perform hand hygiene or glove changes when moving between dirty and clean areas for Resident #22 and Resident #52. Resident #22 was a male resident with diagnoses including irritable bowel syndrome, dysphagia, cognitive communication deficit, Huntington's disease, restlessness and agitation, and abnormalities of gait and mobility. His MDS reflected bowel and bladder incontinence and dependence on two people for ADLs. Resident #52 was a male resident with diagnoses including Alzheimer's disease, restless and agitation, dysphagia, lack of coordination, muscle weakness, and hypertension. His MDS reflected bowel and bladder incontinence and dependence on two people for ADLs. For Resident #22, CNA B cleansed the penis from the base toward the meatus and did not change gloves or perform hand hygiene when moving from the peri area to the bottom or from front to back. For Resident #52, CNA B used the same wipe for the shaft and glans of the penis, then changed gloves without hand hygiene and continued front peri-care, later assisted the resident to his side and continued cleaning the bottom without hand hygiene or changing gloves, and then helped him dress and transfer to his wheelchair before changing gloves and performing hand hygiene. For Resident #3, who had diabetes mellitus type 2, osteomyelitis, an acquired absence of the left great toe, vascular dementia, hypertension, cerebral infarction, and muscle weakness, the care plan reflected Enhanced Barrier Precautions for a wound on the left toe. During wound care, LVN D did not put on a clean gown or mask before providing the treatment.
Worn Bedroom Walls Did Not Support a Homelike Environment
Penalty
Summary
The facility failed to maintain a home-like environment for two residents who shared a bedroom. Resident #2 had diagnoses including Type II Diabetes Mellitus, Schizophrenia, and muscle weakness, and his MDS dated 05/25/2025 showed a BIMS score of 15, indicating no cognitive impairment. Resident #63 had diagnoses including Pseudobulbar Affect, anxiety disorder, and Epilepsy, and his MDS dated 06/26/2025 showed a BIMS score of 0, indicating significant cognitive impairment. During observation on 08/06/2025 at 11:35 AM, the shared bedroom was noted to have scratched up and torn walls next to both residents’ beds. During interview on 08/07/2025, Resident #2 stated the walls had been scratched up since before he arrived at the facility and said the condition of the walls did not make the room feel homelike, making him feel like he lived in a facility rather than a home. Staff interviews confirmed that homelike environment training had been provided and that torn-up walls were not homelike. CNA A, LVN D, the MS, the DON, and the ADM all stated that the MS was responsible for repairs and that staff were to notify supervisors or document issues in the maintenance log or by text message. The ADM stated the condition of the walls would not be homelike if it was not from the resident himself.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent for 1 of 8 residents reviewed for medication administration. Resident #3 was a male with diagnoses including type 2 diabetes mellitus, osteomyelitis, acquired absence of the left great toe, vascular dementia, hypertension, cerebral infarction, and muscle weakness. His quarterly MDS reflected a BIMS score of 4, indicating severe cognitive impairment, and also noted a surgical wound requiring wound care, ointments/medications, and dressings to the feet. His care plan included diabetes-related interventions and monitoring for side effects and effectiveness. During observation of blood glucose monitoring and insulin administration, LVN E did not check the physician order for the sliding-scale parameters and instead relied only on the medication label before administering insulin to Resident #3. During a separate medication pass observation, CMA A did not administer Ferrous Sulfate 325 mg daily and Cholecalciferol 25 mcg daily to Resident #3. When interviewed, CMA A stated he was supposed to give both medications but forgot and documented them on the MAR without actually administering them. The physician orders, care plan, and medication administration policy were reviewed as part of the findings.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure that a call light was accessible while in bed for Resident #2. Resident #2 was a male admitted to the facility with diagnoses of Type II Diabetes Mellitus, Schizophrenia, and muscle weakness. His MDS dated 05/25/2025 showed a BIMS score of 15, indicating no cognitive impairment. During an observation on 08/05/2025 at 12:30 PM, Resident #2's bedroom did not have a call light at the call light spot between the two beds, while the roommate had a call light next to the bed. A later observation on 08/06/2025 at 2:15 PM showed a call light connected to the call light spot and sitting behind Resident #2's bed. During interview on 08/07/2025, Resident #2 stated he had not had his own call button since arriving at the facility and did not know how he would call for help. Facility staff and leadership interviewed on 08/07/2025 stated that call lights are important for resident safety, communication, and access to help, and the facility policy titled Call Lights stated that residents' call lights must be placed within reach and checked for condition and functioning.
Failure to Update Care Plans Leads to Resident Harm
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to significant deficiencies in care. Resident #47, who had a history of dysphagia and was identified as a choking risk, did not have an updated care plan reflecting these needs. Despite a swallow study indicating severe dysphagia and a high risk for aspiration and choking, the care plan lacked necessary interventions and dietary information. This oversight contributed to a fatal choking incident during a meal, where staff attempted the Heimlich maneuver and CPR, but the resident ultimately passed away. Resident #52's care plan was not updated to address his refusal of activities of daily living (ADL) care, including bathing. Despite multiple attempts by staff to encourage hygiene practices, the resident consistently refused, citing past trauma related to water. The care plan did not reflect these refusals or include strategies to manage his hygiene needs, leaving staff without guidance on how to address his non-compliance effectively. Resident #57 exhibited challenging behaviors, such as urinating in inappropriate places and becoming combative with staff. However, these behaviors were not documented in his care plan, leaving staff without a structured approach to manage his actions. Additionally, the care plans for Residents #43 and #67 did not reflect their status as smokers, omitting necessary interventions and timelines for managing their smoking habits. These omissions in care planning could lead to unmet needs and decreased quality of life for the residents.
Inadequate Supervision Leads to Resident Choking Incident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a resident choking and ultimately passing away. The resident, a male with multiple diagnoses including dementia and Alzheimer's, was on a mechanically altered diet and was considered independent in feeding according to his MDS. However, a professional evaluation had diagnosed him with oropharyngeal dysphagia, indicating a risk for choking, and recommended assistance with feeding. Despite this, the resident's care plan did not reflect these needs, and there were no documented dietary orders for a mechanical soft diet. On the day of the incident, the resident began choking during supper. Staff attempted to perform the Heimlich maneuver and clear the airway, but the resident passed out and subsequently died despite CPR efforts. Interviews with staff revealed a lack of awareness regarding the resident's swallowing difficulties and dietary needs. The DON and other staff members were unaware of the resident's diagnosis of swallowing difficulty, and there was no clear communication or documentation of the resident's dietary requirements and risk factors. The facility's failure to monitor the resident during meal intake and to update care plans with necessary interventions for residents at risk of choking contributed to the incident. The lack of a clear policy for following up on swallow study results and notifying the doctor, as well as inadequate supervision during meals, were significant factors in the deficiency. The report highlights the need for improved communication and documentation to ensure resident safety and prevent similar incidents in the future.
Failure to Report Choking Incident Leading to Resident's Death
Penalty
Summary
The facility failed to report an incident involving a resident who choked and subsequently died, which was a violation of the requirement to report alleged violations involving neglect immediately or within two hours if they result in bodily injury. The resident, a male with multiple diagnoses including dementia and Alzheimer's, was on a mechanical soft diet and had a history of swallowing difficulties as indicated by a swallow study. Despite these known issues, the incident was not reported to the State agency, and no investigation was conducted because the incident was witnessed by staff. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed uncertainty about whether the incident needed to be reported. The DON and ADM both stated that they were unsure if the incident should be reported, despite the fact that the resident's death was due to choking, which is considered an unusual circumstance. The DON also mentioned that the resident had missing teeth and no dentures, but claimed the resident did not have swallowing issues, contradicting the swallow study results. Further interviews with nursing staff and a speech pathologist highlighted inconsistencies in the understanding of the resident's condition. The RN who responded to the choking incident was unaware of the resident's swallowing difficulties or dietary restrictions. The speech pathologist confirmed the resident's diagnosis of Oropharyngeal Dysphagia and stated that recommendations were made based on the swallow study. However, the resident's primary doctor and nurse practitioner were either unaware of the swallow study results or did not follow its recommendations, indicating a lack of communication and coordination in the resident's care plan.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure the proper administration of medication to a resident, identified as Resident #1, who was diagnosed with Alzheimer's disease, Parkinson's disease, unspecified psychosis, schizophrenia, COPD, and primary hypertension. During an observation, a white pill was found on the floor of Resident #1's room, which was identified as Depakote, a medication prescribed for schizoaffective disorder. The Director of Nursing (DON) confirmed the medication should have been administered by the night medication aide (MA) and expressed uncertainty about how it ended up on the floor. The DON emphasized the expectation that staff should ensure oral medications are swallowed by residents to prevent potential negative outcomes. Interviews with the night MA and the Administrator (ADM) revealed that the MA claimed to have administered the medication and ensured residents took their medications before leaving. However, the MA was uncertain how the medication was left behind. The ADM reiterated the expectation that medication should not be left unsupervised, as it could lead to another resident taking it or the intended resident not receiving their full dose. The facility's Medication Administration policy mandates that medications be administered within a one-hour window and that the seven rights of medication administration be followed.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who walked out of the facility unattended. The resident, who had a history of mental illness and other medical conditions, was found to be missing on a routine check. The staff member responsible for monitoring the resident every two hours did not physically check on the resident but instead assumed the resident was present, leading to the resident's unnoticed elopement. The resident's care plan indicated that he should be placed in an area where frequent observation was possible due to his habit of intruding into other residents' privacy. Despite this, the resident managed to exit the facility through a secured gate by forcefully opening it. The monitoring sheet falsely indicated that the resident was present throughout the night, even though CCTV footage showed the resident leaving the facility. Interviews with staff revealed that the night nurse did not physically check on the residents but used a flashlight from the door for observation. The facility's policy required physical checks every two hours, but this was not followed. The Director of Nursing acknowledged that there was no system in place to verify the accuracy of these observations, contributing to the resident's elopement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Sedona Trace Health And Wellness Center | 3.8 mi | ★★★★★ | 3 | 0 |
| Legend Oaks Healthcare And Rehabilitation - North | 4 mi | ★★★★★ | 11 | 2 |
| Heritage Park Rehabilitation And Skilled Nursing C | 6.4 mi | ★★★★★ | 8 | 1 |
| Gracy Woods Ii Living Center | 6.9 mi | ★★★★★ | 0 | 0 |
| Gracy Woods Nursing Center | 7 mi | — | 21 | 1 |
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