Inspection Reports for
Generations at Oakton Arms

Investigation unable to be completed due to subject of the complaint not residing at the facility.

The investigation was unable to be completed because the subject of the complaint did not reside at the facility.

The facility was found deficient in multiple areas including failure to involve residents in fire drills and document evacuation assistance, lack of proper CPR certification and demonstration for staff, incomplete employee orientation documentation, physician assessments signed by non-physicians, incomplete service plans especially regarding shower assistance and medication interventions, and failure to meet fire drill time constraints. These deficiencies pose substantial probability of harm to residents.

The complaint investigation substantiated that a resident was physically and verbally abused by a nurse. The resident was injured and transported to the emergency room. The resident expressed fear and requested discharge against medical advice. The nurse was suspended pending investigation.

The facility failed to ensure a resident remained free from staff to resident abuse, resulting in physical injuries to the resident and an emergency room visit. The investigation included review of video footage and interviews, confirming an altercation between a nurse and the resident that escalated instead of being diffused.

The complaint was substantiated. The resident reported multiple requests for wound care that were ignored by nursing staff and wound care nurse. The resident independently removed the wound vac device and was not treated for 5 hours, leading to calling 911 and hospital transfer.

The facility failed to follow physician orders for negative pressure wound therapy and dressing for a resident, resulting in the resident not receiving wound treatment for 5 hours. Staff did not respond to the resident's requests for wound care, leading to the resident's condition worsening and eventual hospital transfer.

The facility failed to ensure consistent cleaning and sanitization of residents' rooms and medical equipment, proper feeding tube site care according to physician orders, and adequate hydration for a resident dependent on tube feeding. These failures affected four residents and resulted in minimal to actual harm, including hospitalization for dehydration.

The investigation was triggered by a complaint related to a fall of resident R1 during transfer. The complaint was substantiated as the facility failed to follow the resident's care plan and safety protocols, resulting in injury.

The facility failed to ensure proper transfer techniques and appropriate footwear for resident R1, which led to a fall causing a neck fracture and hospitalization. The staff did not use a required gait belt despite the resident's care plan and assessment indicating maximal assistance needed during transfers.

The complaint was substantiated. The investigation found failures in catheter care and urine specimen collection that led to a resident's severe UTI and hospitalization. The grievance form was incomplete, and staff failed to document or act timely on clinical signs and lab orders.

The facility failed to provide appropriate catheter care, timely obtain urine specimens, document urine output, and respond to signs of urinary tract infections for two residents with indwelling catheters. These failures resulted in one resident requiring emergency treatment and hospitalization for severe UTI with sepsis.

The complaint was substantiated as the facility failed to provide a recliner wheelchair to resident R12 after hospice services ended, limiting the resident's mobility and ability to get out of bed.

The facility failed to provide a recliner wheelchair to resident R12 after hospice services were discontinued, resulting in the resident remaining in bed despite expressing a desire to get up. Staff acknowledged the lack of wheelchair provision and the facility policy expects residents to have wheelchairs as needed.

The complaint investigation was substantiated. The resident (R1) fell out of an unlocked wheelchair in an unsupervised dining room, sustaining bruising and a cut above the left eye requiring four sutures and hospital evaluation.

The facility failed to ensure the wheelchair locking mechanism was engaged and failed to provide adequate supervision for a high-risk resident, resulting in the resident falling and sustaining injuries requiring hospital evaluation and sutures. Staff interviews and record reviews confirmed the wheelchair was only partially locked and no staff supervised the resident in the dining room at the time of the fall.

The facility failed to follow physician orders for transmission-based precautions for one resident and failed to perform proper hand hygiene and use of personal protective equipment (PPE) by staff, increasing the risk of infection spread.

The investigation was triggered by a fall incident on 11/20/2023 involving resident R2, a high fall risk individual. The fall was not directly witnessed by staff, though some staff heard the fall. The resident sustained injuries requiring hospital evaluation and sutures. The complaint was substantiated with findings of inadequate supervision and lack of a formal monitoring policy.

The facility failed to adequately supervise a high fall risk resident, resulting in the resident falling from a wheelchair and sustaining a laceration requiring sutures. Staff accounts conflicted on whether the fall was witnessed, and observations revealed residents in the dining room were often unsupervised. The facility lacked a formal policy on monitoring high fall risk residents.

The investigation was triggered by complaints regarding a resident fall and improper catheter care. The fall was substantiated with findings of inadequate supervision and mattress missettings. The catheter care complaint was substantiated with findings of improper catheter bag placement and unsecured tubing.

The facility failed to ensure adequate supervision to prevent a resident's fall and failed to properly secure a resident's urinary catheter bag, increasing risk of infection. Both incidents involved failure to follow established care policies and procedures.

The facility failed to implement effective pressure ulcer prevention measures for one resident, including improper use of a pressure relief mattress. Additionally, the facility failed to provide necessary therapy and interventions to prevent decline in range of motion for another resident, resulting in a contracture.

The complaint investigation found substantiated failures in incident reporting, documentation, monitoring, notification, and fall prevention practices related to residents R1 and R2. The failures caused actual harm, including delayed treatment and hospitalization of R1 for a left femoral neck fracture.

The facility failed to complete incident reports, document progress notes, assess and monitor residents for changes after falls, notify physicians and families immediately, and implement fall prevention interventions or update fall care plans for residents. These failures resulted in delayed treatment and hospitalization of a resident with a fractured femoral neck.

The complaint investigation was triggered by an allegation that a CNA verbally abused and physically assaulted a resident by throwing the resident's legs into bed and using inappropriate language. The allegation was reported to the Administrator, police were notified, and the CNA was suspended. The investigation was ongoing but unable to substantiate abuse at the time of the report.

The investigation found that a CNA forcibly grabbed and threw the resident's legs into bed and used inappropriate language. The resident complained of mild shoulder pain but had no injuries on assessment. The CNA was suspended pending investigation and police were involved.

The complaint investigation focused on the fall incident of resident R1 on 8/12/2023, the facility's failure to implement effective fall prevention measures, and inadequate pain management following the fall. The resident suffered a displaced left femur fracture and sepsis. The investigation included interviews with staff and family, record reviews, and assessment of facility policies.

The facility failed to implement and reevaluate fall prevention interventions for a high-risk resident, resulting in a fall causing a displaced left femur fracture and sepsis. Additionally, the facility failed to provide adequate pain management post-fall, despite family and staff reports of the resident's pain.

The facility was found deficient in multiple areas including failure to treat residents with dignity during medication administration, lack of accessibility to state inspection survey results for residents, improper pressure settings on alternating pressure air mattresses for residents at risk of pressure ulcers, failure to keep catheter collection bags off the floor, and incomplete controlled medication receipt documentation.

The facility failed to follow the individualized plan of care for pressure ulcer interventions by not turning and repositioning a resident every two hours as required. This failure affected one resident with a pressure ulcer, potentially impacting wound healing.

No health deficiencies were found during the inspection.

The facility failed to update care plans after falls, administer medications per physician orders, maintain grooming standards, implement restorative care interventions, ensure effective fall prevention measures, stabilize urinary catheters, properly account for controlled substances, maintain safe medication refrigerator temperatures, and follow infection prevention and control protocols including transmission-based precautions.