Inspection Reports for
Country Oaks Care Center

The facility was found deficient in developing and implementing complete care plans for residents with medical devices, providing treatment according to physician orders, and ensuring nursing staff competency in managing Pleurx catheters. These deficiencies posed potential risks to resident safety and well-being.

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 failed to ensure two staff members assisted with mechanical lifts for Resident 1, maintain accurate medical records for Resident 3 regarding G-tube site issues, and enforce proper hand hygiene and glove use by staff caring for Resident 3 under Enhanced Barrier Precautions.

The facility had multiple deficiencies including failure to maintain call lights within reach, inadequate advance directive communication, unsafe and unsanitary environmental conditions, inaccurate resident assessments, incomplete care plans, inadequate fall prevention supervision, improper catheter care, feeding tube care issues, IV site labeling omissions, improper medication administration, infection control lapses, food handling violations, and insufficient room space per resident.

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 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 was substantiated based on observations, interviews, and record reviews indicating CNA 1 physically and verbally abused Resident 1 on 10/27/2024. Two sitters witnessed the abuse and reported it. 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 and verbally abusive 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 facility failed to ensure timely receipt of abdominal X-ray results for 2 of 3 sampled residents, resulting in delays of 3 days in resuming G-tube feeding and medications. Licensed nurses experienced delays with a new diagnostic company, causing one resident to be sent to a hospital for G-tube placement 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 facility failed to ensure that four of six sampled Licensed Vocational Nurses received required in-service training before signing training forms. Staff reported signing training forms without receiving actual training, and the facility lacked a system to track completed trainings.

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 investigation was complaint-driven, focusing on allegations that residents were not receiving timely incontinence care and that staffing levels were insufficient. Interviews with CNAs and nursing staff confirmed residents were often found soaked with urine due to inadequate care and staffing shortages. The complaint was substantiated with findings of care deficiencies and staffing inadequacies.

The facility failed to provide appropriate incontinence care every two hours for two sampled residents, placing them at risk for urinary tract infections and skin breakdown. Additionally, the facility did not provide sufficient nursing staff during night shifts to meet residents' needs, and 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 facility failed to ensure that Certified Nurse Assistants used the Hoyer lift appropriately during resident transfers, resulting in residents being at risk for falls and injury. Staff did not consistently follow the facility's policy requiring two staff members for safe mechanical lift transfers, and improper handling techniques were observed.

The facility failed to conduct a reference check before hiring one of three sampled staff, a Certified Nursing Assistant, which placed 70 residents at risk for abuse. The facility's policy requires background and reference checks for potential employees, but documentation showed this was not done for the staff member.

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 housekeeping staff wore gloves on both hands and performed hand hygiene before and after tasks. The facility also failed to ensure the soiled linen barrel was covered during transport, posing a risk of cross-contamination and infection spread.

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 investigation was complaint-driven, focusing on allegations of disrespectful staff behavior, inaccessible call light for Resident 4, and unsanitary shower rooms. The findings substantiated these complaints with minimal harm noted.

The facility failed to maintain resident dignity by staff behavior towards Resident 4, failed to ensure Resident 4's call light was within reach, and failed to maintain cleanliness in two shower rooms, resulting in unsanitary conditions.

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 substantiated that Resident 2 physically abused Resident 1 by hitting her on the arm after being provoked by name-calling. Multiple staff interviews and record reviews confirmed the incident and the facility's failure to prevent it.

The facility failed to prevent physical abuse between residents, specifically Resident 2 hitting Resident 1. The investigation found that Resident 2 was agitated and hit Resident 1 after being called an idiot, and the facility's policies on abuse prevention were reviewed.

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 involved an allegation that Resident 4 grabbed Resident 2's arm multiple times, which was considered resident-to-resident physical abuse. The allegation was substantiated by interviews and record reviews. The Administrator did not report the incident timely, violating reporting requirements.

The facility failed to report an allegation of resident-to-resident physical abuse within the required two-hour timeframe. The Administrator delayed reporting the incident to the Department of Public Health by 15 days, which could compromise resident safety and allow abuse to reoccur.

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, causing Resident 1 to feel depressed and undignified.

The facility failed to provide Resident 1, who was occasionally incontinent and had mobility issues, with alternative toileting methods and assistance, causing Resident 1 to urinate in briefs instead of being assisted to use a bed pan or toilet. This failure led to Resident 1 feeling depressed, like a burden, and treated without dignity, potentially worsening continence and psychosocial health.

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. Additionally, the facility failed to complete fall risk assessments for Residents 2 and 3, resulting in incomplete evaluations of their fall risk.

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 Policy by not reviewing and revising Resident 2's care plan interventions for effectiveness after each fall. Resident 2 experienced five falls within 38 days, and there was no evidence that care plan interventions were updated following the falls on 2/18/24 and 3/5/24.

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 policy, posing a risk of delayed assistance and potential harm. Observations and interviews confirmed the call light was often misplaced and inaccessible, contrary to the care plan and facility procedures.

The facility was found deficient in multiple areas including resident dignity, care planning, treatment and monitoring of edema, pressure ulcer care, continence care, weight monitoring, respiratory care, medication regimen review, psychotropic medication monitoring, infection control, facility staffing assessment, resident room size compliance, and environmental safety.

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 facility failed to ensure one resident received food according to the prescribed therapeutic diet, potentially impacting the resident's health. Additionally, the facility failed to properly monitor and store resident snacks and nourishments under refrigeration, risking foodborne illness for multiple residents.

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, failed to prevent new pressure injuries, and lacked competent wound care among nursing staff. Additionally, the facility failed to accurately document medication administration for one resident, leading to potential medication errors.

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 revealed Resident 1's behaviors included unauthorized recording of other residents, entering restricted areas, leaving the facility unsupervised without physician orders, and aggressive conduct toward staff. The investigation substantiated immediate jeopardy due to failure to provide behavioral health care and protect residents' safety and rights.

The facility failed to provide adequate behavioral health care and services to Resident 1, who exhibited aggressive behaviors, unauthorized access to restricted areas, and repeatedly recorded other residents without consent. These failures placed Residents 1, 2, 3, and 4 at risk of harm and violated residents' rights to privacy and safety.

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 found that Resident 1, a Spanish-speaking resident, was not provided discharge paperwork or notification of appeal rights in Spanish. Interviews with staff confirmed the resident was not informed of the right to appeal the discharge. The facility policy required information to be provided in a language understood by the resident, but documents were only provided in English. Resident 1 expressed discomfort with the discharge and lack of follow-up appointments and stated he would have appealed if informed of his rights.

The facility failed to notify Resident 1 of the transfer or discharge and the reasons for the move in writing and in a language the resident could understand (Spanish). The discharge planning information was provided only in English, which placed the resident at risk of not being fully informed of appeal rights and options.

The complaint investigation found that Resident 1 did not receive routine oxycodone pain medication on 12/30/2022 and 12/31/2022 due to the facility not ordering the medication timely from the pharmacy. The facility staff acknowledged the medication should have been ordered five days before running out but was only ordered on 12/31/2022. The facility's emergency kit did not carry oxycodone.

The facility failed to ensure that Resident 1 received routine pain medication oxycodone for two days due to delayed pharmacy delivery and ordering issues. This failure had the potential to cause excruciating and uncontrollable pain for Resident 1.

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 facility maintenance.

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 investigation was complaint-driven, focusing on Resident 1's lack of oral hygiene, physical and occupational therapy, nephrostomy catheter care, medically related social services, and dental follow-up. Substantiation status is not explicitly stated.

The facility failed to provide mouth hygiene, physical and occupational therapy services, proper 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.

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.