Ascension Oaks Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Ascension Oaks Nursing & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jun 26, 2024

  Based on observation, interview and record review, the facility failed to provide supervision to the facility's staff to keep a resident's environment free of accidents/hazards by failing to ensure: 1. The facility's staff transferred a resident with a [NAME]- Lift (a mechanical lift used to transfer residents) per the facility's policy (Resident #69); and, 2. The facility's staff properly laundered [NAME]-Lift slings (slings used to transfer residents with the mechanical lift). This deficient practice resulted in an Immediate Jeopardy situation on 04/14/2024 at 6:05 p.m. […]

• Immediate jeopardy, patternF726Jun 26, 2024

  Based on observation, interview and record review, the facility failed to ensure: 1. The facility's staff (S8Certified Nursing Assistant [CNA]) was trained and deemed competent to transfer a resident using a [NAME]-Lift (a mechanical lift used to transfer residents) as per the manufacturer's guidelines (Resident #69); and, 2. A qualified individual, who was trained and competent, was assigned the task of evaluating if the facility's staff were competent with transferring residents using a [NAME]-Lift per the manufacturer's guidelines (S13CNA Supervisor). This deficient practice resulted in an Immediate Jeopardy situation on 04/14/2024 at 6:05 p.m. […]

• Immediate jeopardy, patternF835Jun 26, 2024

  Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure: 1. The facility's staff transferred a resident with a [NAME]-Lift (a mechanical lift used to transfer residents) per the facility's policy (Resident #69); 2. The facility's staff properly laundered [NAME]-Lift slings (slings used to transfer residents with the mechanical lift); and 3. Facility administration ensured competency of assigned trainers and staff on the use and care of the [NAME]-Lift and slings prior to allowing staff to transfer residents. This lack of administrative oversight resulted in Immediate Jeopardy situation on 04/14/2024 at 6:05 p.m. […]

• Actual harm, isolatedF689Mar 5, 2024

  Based on interviews and record reviews, the facility failed to ensure a resident's assistive device was available for use to decrease the risk of falls for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accident hazards. This deficient practice resulted in actual harm on 02/21/2024 at 6:26 p.m. when S2Certified Nursing Assistant (CNA) removed Resident #1's wheelchair from her room and placed it in the hallway. Resident #1 was unable to access her wheelchair to assist with mobility. On 02/21/2024 at 7:48 p.m. Resident #1 was found sitting on a fall matt next to her bed. On 02/22/2024 Resident #1 complained of pain in the left upper leg and was diagnosed with a left femur fracture which required hospitalization and surgical repair. […]

• No harm, potential for more than minimal, widespreadF838Jun 26, 2024

  Based on record review and interview, the facility failed to have a facility-wide assessment which addressed all components. Findings: Review of the Facility assessment dated [DATE] and reviewed 06/14/2024 revealed the following sections were not addressed in the facility-wide assessment: 1. Staff competencies; 2. The physical environment and equipment; 3. Any ethnic, cultural, or religious factors; and, 4. The facility's resources. In an interview on 06/26/2024 at 12:47p.m., S14Regional Director of Operations indicated as of today (06/26/2024), the facility had not completed Section 3 of the facility-wide assessment. […]