Inspection Reports for
Oakridge of Plattsburg

The complaint investigation found that Resident #1 was left unattended with hot food and sustained burns to the right hand fingers. The incident was witnessed by Resident #2. The facility was notified on 2025-10-07, and an investigation and corrective actions were promptly initiated.

The facility failed to provide adequate supervision and a safe dining environment for one resident who sustained burns to the fingers when left unattended during meal service. Corrective actions including staff training and new meal service policies were implemented and the non-compliance was corrected on 2025-10-07.

The facility was found deficient in multiple areas including safe and homelike environment, ADL care for dependent residents, accident prevention, bedrails safety, medication administration, food safety, and infection control. Several residents were affected by these deficiencies, and the facility failed to follow policies and procedures in these areas.

The facility was found deficient in testing and maintenance of the fire alarm system, HVAC system operation, and improper use of power strips in resident rooms. The facility had a capacity of 120 beds with a census of 55 or 68 residents noted in different findings.

The facility was found deficient in multiple areas including environmental cleanliness and maintenance, inadequate personal care and hygiene for dependent residents, unsafe wheelchair practices, improper use and assessment of bed rails, medication administration errors, food safety violations, and failure to implement proper infection prevention and control measures.

The facility was found deficient in multiple areas including failure to treat residents with dignity during assistive dining, inadequate accounting and security of residents' personal funds, failure to provide proper notice before transfer or discharge, and insufficient care for dependent residents in activities of daily living and restorative nursing care.

The facility failed to ensure staff treated residents with dignity during dining by standing while assisting residents to eat. The facility also failed to keep residents' money separate from the facility's operating account and maintain a sufficient surety bond. Additionally, the facility did not provide timely and complete written transfer/discharge notices, failed to provide complete perineal care to dependent residents, and lacked an active restorative therapy program to maintain or improve residents' range of motion.

The complaint investigation substantiated that staff verbally and physically abused four sampled residents. The facility failed to report these allegations immediately to the charge nurse, Director of Nursing, or Administrator. The allegations were reported late to local police and facility leadership.

The facility failed to develop and implement adequate abuse and neglect policies and failed to report observed abuse incidents in a timely manner. Multiple residents experienced verbal and physical abuse by staff, and the facility did not properly report or investigate these allegations.

The facility failed to notify the physician promptly about a resident's injury and did not provide adequate supervision to prevent accidents. The resident with a fractured left humerus was not properly monitored, and the facility lacked policies for accident prevention and notification.

The complaint investigation was substantiated as the facility failed to promptly investigate and report abuse allegations involving Resident #1. The alleged perpetrator was suspended pending the outcome of the investigation.

The facility failed to initiate an immediate investigation when a staff member reported rough treatment of a resident, allowing the alleged perpetrator to continue working unsupervised for two hours. The investigation revealed multiple incidents of rough handling and failure to report abuse promptly to management.

The facility was found to be out of compliance with infection prevention and control requirements, specifically failing to properly prevent the potential spread of COVID-19 due to inadequate isolation and transmission-based precautions for a symptomatic resident.

The facility failed to ensure staff followed physician orders for administering Tamiflu to three residents, resulting in missed doses and failure to notify physicians when medication was refused. The facility census was 57 at the time of inspection.

The facility failed to check the Nurse Aide Registry for all new hires, provide written transfer/discharge notices and bed hold policy information to residents, develop and implement complete care plans for residents, follow physician orders for oxygen monitoring and catheter care, ensure call lights and water pitchers were accessible to residents, and properly discard expired medications from medication carts. Several residents were affected by these deficiencies, with minimal harm noted.

The facility was found deficient in multiple areas including failure to conduct nurse aide registry checks for new hires, inadequate notice requirements before resident transfer or discharge, failure to implement comprehensive care plans, improper medication storage and labeling, and failure to follow bed-hold policies. Several residents' care plans and medical records lacked required documentation and interventions.

The facility failed to meet several Life Safety Code requirements including maintenance of sprinkler systems, emergency exit doors, emergency lighting, corridor doors, and electrical equipment safety. The emergency preparedness program was also found deficient in documentation and planning.

The facility was found to have multiple deficiencies including failure to maintain a safe, clean, and homelike environment, inadequate investigation of alleged abuse, failure to meet professional standards in medication administration, insufficient care for dependent residents, unsafe transfer practices, and improper respiratory care. The facility submitted a plan of correction addressing these issues.