Inspection Reports for
Country Oaks Care Center

The facility failed to develop a timely and complete care plan for a resident with a Pleurx catheter, failed to obtain a physician's order prior to catheter drainage, and failed to ensure competency assessments for licensed nurses managing Pleurx catheters. These deficiencies posed risks of unmet needs, physical decline, and compromised safety for residents.

The facility was found deficient in ensuring safe resident handling by not using two staff members during mechanical lifts, failing to maintain accurate medical records regarding a resident's gastrostomy tube condition, and not following infection control protocols including hand hygiene and glove use by staff caring for a resident on Enhanced Barrier Precautions.

The facility was found deficient in multiple areas including failure to ensure call lights were within reach, inadequate advance directive information provided to responsible parties, unsafe and unsanitary environmental conditions in kitchen, resident rooms, and bathrooms, inaccurate resident assessments, incomplete care plans, inadequate supervision to prevent falls, improper catheter care, feeding tube care deficiencies, improper IV site care, incorrect medication administration, failure to ensure staff competency in gastrostomy tube care, improper food handling practices, failure to implement infection control precautions, and inadequate resident room space.

The facility failed to develop and implement a comprehensive person-centered care plan addressing a resident's refusal to be changed when soiled, posing a risk for urinary tract infection. Additionally, the facility failed to provide a safe and comfortable environment by allowing a trash can liner to be tied to a resident's overhead light pull cord, which was too short and not properly replaced.

The complaint was substantiated based on observations, interviews with CNA 1, two sitters, and record reviews indicating CNA 1 physically and verbally abused Resident 1 on 10/27/2024. CNA 1 was suspended pending investigation.

The facility failed to protect Resident 1 from verbal and physical abuse by CNA 1, who was observed and reported by two sitters to have been aggressive, verbally abusive, and physically mistreating Resident 1 during care. CNA 1 was suspended pending investigation.

The complaint investigation found that abdominal X-ray results for Resident 1 and Resident 2 were delayed, causing a 3-day interruption in gastrostomy tube feeding and medication. Licensed nurses contacted the diagnostic company multiple times without receiving results promptly. Resident 1 was sent to a general acute care hospital for G-tube placement confirmation due to the delay. Interviews with nursing staff and the Director of Nursing confirmed the importance of timely X-ray results and noted issues with the new diagnostic company.

The facility failed to ensure timely receipt of abdominal X-ray results for 2 of 3 sampled residents, resulting in delays of up to 3 days in resuming gastrostomy tube feeding and medications. Licensed nurses repeatedly contacted the diagnostic company without success, leading to one resident being sent to an acute care hospital for confirmation.

The complaint investigation found substantiated issues where LVNs were instructed to sign In-service Forms without receiving the actual training, described by staff as signing a 'blank check' and covering for the facility.

The facility failed to ensure that four of six sampled Licensed Vocational Nurses received required In-service training before signing training documentation. Staff interviews confirmed that multiple In-service Forms were signed without actual training, posing potential risks to resident safety and care quality.

The complaint investigation found substantiated failures related to incontinence care and staffing shortages that placed residents at risk for skin breakdown and urinary tract infections. Interviews with CNAs and nursing staff confirmed inadequate staffing and delayed care. The facility's policies require checking incontinent residents every two hours, which was not consistently followed.

The facility failed to ensure appropriate incontinence care was provided every two hours for two sampled residents, placing them at risk for skin breakdown and urinary tract infections. Additionally, the facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed care. The facility also failed to post nurse staffing information daily as required.

The facility failed to ensure that Certified Nurse Assistants used the Hoyer lift appropriately during resident transfers, resulting in four of eight sampled residents being at risk for falls and injury. Staff did not follow proper procedures, including inadequate assistance during transfers and improper handling of residents' feet instead of the sling.

The complaint investigation found that the facility did not conduct reference checks as required by their policy, placing residents at risk for abuse. The deficiency was substantiated based on interviews and record review.

The facility failed to conduct required reference checks before hiring CNA 1, which placed 70 residents at risk for abuse. The facility's policy mandates background and reference checks to prevent abuse, neglect, and exploitation, but documentation showed no evidence that these checks were performed for CNA 1.

The facility failed to ensure that Housekeeping staff wore gloves properly and performed hand hygiene before and after tasks, and failed to cover the soiled linen barrel during transport, which posed a risk of cross-contamination and infection spread.

The facility was found deficient in maintaining resident dignity, ensuring call lights were within reach, and keeping shower rooms clean. These deficiencies posed potential harm or discomfort to residents but were classified as minimal harm or potential for actual harm.

The complaint investigation found that Resident 2 hit Resident 1 after Resident 1 called Resident 2 a 'stupid idiot.' The incident was witnessed by staff and resulted in Resident 1 being discharged to an Assisted Living facility with Dementia/Alzheimer's care. The facility's staff and policies were reviewed in relation to the incident.

The facility failed to prevent physical abuse between residents, specifically Resident 2 hitting Resident 1, which had the potential to cause a decline in Resident 1's physical and psychosocial well-being. Multiple interviews and record reviews confirmed the incident and the facility's policies on abuse prevention were reviewed.

The complaint investigation found that the facility did not report an allegation of resident-to-resident abuse involving Resident 2 and Resident 4 within the required two-hour timeframe. The Administrator did not consider the incident abuse initially and reported it 15 days later. Interviews with staff and residents confirmed the abuse and the failure to report timely.

The facility failed to report an allegation of resident-to-resident physical abuse within the required two-hour timeframe. The Administrator, who is the abuse coordinator, reported the incident 15 days late. The failure to report had the potential to compromise resident safety and allow further abuse to occur. Interviews and record reviews confirmed the incident and the delayed reporting.

The complaint investigation substantiated that Resident 1 was not provided with appropriate toileting assistance despite being continent and able to verbalize needs. Staff told Resident 1 to urinate in briefs due to difficulty assisting with mobility, which caused Resident 1 emotional distress and potential decline in continence.

The facility failed to provide Resident 1, who was occasionally incontinent and had mobility issues, with appropriate toileting assistance and alternative methods to use the bathroom as indicated in the care plan. Staff instructed Resident 1 to urinate in an incontinence brief instead of assisting with a bed pan or toilet, causing Resident 1 to feel depressed, like a burden, and undignified. This failure had the potential to worsen Resident 1's continence status and psychosocial well-being.

The facility failed to implement a care plan intervention to prevent falls for Resident 2 by not placing the floor mat on the correct side of the bed, and failed to complete fall risk assessments for Residents 2 and 3, potentially resulting in inaccurate fall risk evaluations.

The facility failed to implement its Fall Prevention Program effectively for Resident 2 by not reviewing and revising the care plan interventions after each fall. Resident 2 had five falls within 38 days, and there was no evidence that care plan interventions were reviewed for effectiveness after the last two falls.

The facility failed to ensure that Resident 14's call light was within reach as required by the facility's policy and care plan, potentially risking delayed assistance and harm. Observations and interviews confirmed the call light was often out of reach, and staff acknowledged lapses in ensuring the call light was properly positioned.

The facility was found deficient in multiple areas including failure to maintain resident dignity related to catheter care, incomplete care plans for edema management, inadequate monitoring of edema, improper pressure ulcer care, failure to implement a prompted toileting program, missed weekly weights for a resident with weight loss, improper respiratory care, failure to communicate pharmacist recommendations, inadequate monitoring of psychotropic medication effects, incomplete facility staffing assessment, infection control lapses including failure to implement enhanced barrier precautions, inadequate resident room size, and unsafe environment due to a leaking ceiling.

The visit was complaint-related, focusing on therapeutic diet compliance and food safety. The complaint was substantiated as deficiencies were found related to diet orders and food storage.

The facility failed to ensure one sampled resident received food according to the prescribed therapeutic diet, potentially impacting the resident's health. Additionally, the facility failed to properly store resident snacks and nourishments under refrigeration, posing a risk of foodborne illness to multiple residents.

The facility failed to develop and implement individualized care plans for pressure ulcers and wounds for two sampled residents, failed to prevent new pressure injuries, and lacked staff competency in wound care. Additionally, there was inaccurate medication administration documentation for one resident, with falsification of records by nursing staff.

The complaint investigation revealed Resident 1's unsafe behaviors including unauthorized video recording of other residents, aggressive behavior toward staff, and unsupervised therapeutic leave without physician orders. Immediate Jeopardy was called on 4/25/2023 and removed on 4/27/2023 after the facility submitted an acceptable removal plan including psychiatric evaluation and staff training.

The facility failed to ensure Resident 1 received necessary behavioral health care and services, resulting in unsafe behaviors including unauthorized video recording of Residents 2 and 4, aggressive behavior toward staff, and unsupervised therapeutic leave leading to a motor vehicle accident. The facility also failed to protect the rights and safety of Residents 2, 3, and 4 from Resident 1's behaviors. Immediate Jeopardy was called and later removed after corrective actions were implemented.

The complaint investigation found that Resident 1 was not provided the Notice of Proposed Transfer/Discharge or informed of his rights to appeal the discharge in Spanish. Interviews with facility staff confirmed that discharge paperwork was only provided in English and that Resident 1 was not informed of his appeal rights. Resident 1 stated he did not feel safe being discharged without follow-up appointments and would have appealed if informed of his rights.

The facility failed to provide Resident 1, who is Spanish-speaking, with written discharge planning information in Spanish, instead providing it only in English. This failure placed the resident at risk of not being fully informed of his appeal rights and options, potentially resulting in inappropriate transfer or discharge.

The complaint investigation substantiated that Resident 1 did not receive her routine pain medication oxycodone 10 mg on 12/30/2022 and 12/31/2022. The facility staff failed to reorder the medication five days before it ran out, resulting in no medication availability and missed doses.

The facility failed to ensure that Resident 1 received her routine pain medication, oxycodone 10 mg, for two days (12/30/2022 and 12/31/2022) due to delayed pharmacy delivery and failure to reorder medication timely. This resulted in potential for Resident 1 to experience excruciating and uncontrollable pain. Interviews and record reviews confirmed multiple missed doses and documentation errors.

The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, call light accessibility, noise complaint responsiveness, safe environment maintenance, care plan implementation, communication and ADL care, pressure ulcer prevention, accident hazard prevention, respiratory care, dialysis care, medication management, infection control, antibiotic stewardship, COVID-19 vaccination policy, and maintenance of equipment.

The facility failed to provide adequate mouth hygiene, physical therapy, nephrostomy catheter care, medically related social services including therapy and urology follow-up, and dental services for Resident 1. These deficiencies had the potential to cause periodontal disease, muscle wasting, urinary tract infections, sepsis, and decline in physical and psychosocial well-being.