Indianspring of Oakley

In the surveyor’s words

From the most serious findings on record at Indianspring of Oakley, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 1, 2025

  Based on medical record review, review of staff witness statements, review of hospital records, review of facility Interdisciplinary Team (IDT) fall follow-up notes, staff interview, review of online clinical resources per Medline Plus Medical Encyclopedia, and review of the facility policy, the facility staff failed to safely and properly position a resident in bed during incontinence care. Actual Harm occurred on 05/30/25 when Certified Nursing Assistant (CNA) #521 rolled Resident #108 who was in a raised bed away from the aide and onto the floor, resulting in a right nondisplaced intertrochanteric hip fracture which required a hospital admission and subsequent surgical repair of the right hip fracture on 06/02/25. This affected one (Resident #108) of three residents reviewed for falls. […]

• Actual harm, isolatedF686Apr 18, 2024

  Based on medical record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to adequately assess and monitor a resident's skin which resulted in Actual Harm for Resident #20 who was admitted to the facility without pressure ulcers and developed a stage three pressure ulcer (a full thickness skin break into the subcutaneous tissue which did not go into muscle or bone) to the right ischium which was not identified until it had reached an advanced stage. This affected one (Resident #20) of three residents reviewed for pressure ulcers. The facility census was 113. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  Based on observation, staff interview and review of facility policy, the facility failed to ensure refrigerated food was maintained at or below 41 degrees Fahrenheit (F). This had the potential to affect 121 of 123 residents of the facility, excluding two facility-identified residents who received no food by mouth (NPO). The facility census was 123 residents. Findings include: Observation of the facility kitchen on 06/23/2025 at 9:28 A.M. revealed the inside of the walk-in refrigerator was warm. The thermometer on the outside of the door read 60 degrees F. There was no thermometer was located inside the refrigerator. Interview on 06/23/25 at 9:28 A.M. […]

• No harm, potential for more than minimal, widespreadF814Jul 1, 2025

  Based on observation and staff interview, the facility failed to ensure garbage cans in the main kitchen were covered with lids. This had the potential to affect 121 of 123 residents of the facility, excluding two facility-identified residents who received no food by mouth (NPO). The facility census was 123 residents. Findings include: Observation on 06/23/25 at 9:28 A.M. revealed there were three garbage cans in use in the main kitchen which did not have lids. Interview on 06/23/25 at 9:29 A.M. Executive Chef (EC) #601 confirmed the three garbage cans in use in the main kitchen did not have lids and the lids would need to be ordered. Observation on 06/25/25 at 9:48 A.M. revealed the three garbage cans in use in the main kitchen did not have lids. Interview on 06/25/25 at 9:49 A.M. […]

• No harm, potential for more than minimal, widespreadF880Mar 29, 2021

  Based on medical record review, observations, staff interview, review of the facility's personal protective equipment (PPE) guidelines, and review of the Centers for Disease Control (CDC) guidelines, the facility failed to use PPE appropriately in order to potentially prevent the spread of the Coronavirus (COVID-19). This had the potential to affect all 101 residents of the facility. Findings include: 1. Medical record review revealed Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 03/18/21 at 8:11 A.M. revealed Housekeeper #41 to be on the facility's quarantine unit cleaning Resident #86's room. Housekeeper #41 was wearing a N95 respirator/face mask and a face shield, however she she did not have a gown or gloves on. […]