Oak Crest

In the surveyor’s words

From the most serious findings on record at Oak Crest, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF761Sep 12, 2024

  Based on observation, interview, and record review the facility failed to ensure a multi-dose vial was labeled when opened and failed to ensure controlled medications were double locked. This has the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 9/10/24 showed six residents reside in the certified unit of the facility. 1. On 9/12/24 at 9:05 AM, the facility medication room was reviewed. The unit refrigerator had an opened vial of multi-dose tuberculin (TB) solution inside, and it was approximately half dispensed. The vial was not dated or labeled with an open or expiration day. V9 (Registered Nurse) was present and verified the vial was half used and there was no labeling. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2024

  Based on observation, interview, and record review the facility failed to store frozen items off the floor. This failure has the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/24 showed 6 residents reside in certified beds. On 9/11/24 at 11:15 AM and 12:30 PM (One hour and fifteen minutes) a box of lemon and cream cakes was stored on the floor of the walk-in freezer. On 9/11/24 at 11:15 AM, V7 Kitchen Manager stated the facility did not receive a food delivery that day. On 9/11/24 at 12:43 PM, V7 stated the lemon cake was the desert for dinner that evening. […]

• No harm, potential for more than minimal, widespreadF880Sep 12, 2024

  Based on interview and record review the facility failed to have a Legionella (bacteria) prevention and mitigation program in place. The facility also failed to implement enhanced barrier protections (EBP) for a resident with an indwelling catheter. These failures have the potential to affect all residents in the facility. The findings include: The CMS 671 dated 9/10/22 showed 6 residents reside in certified beds. 1. On 9/11/24 at 1:04 PM, V2 Director of Nursing stated V6 Facility Director was responsible for the Legionella program (a bacteria that can cause pneumonia). The facility's Legionella policies for prevention and mitigation were requested from V2. On 9/11/24 at 2:09 PM, V6 stated he has been the maintenance director for 8 months. […]

• No harm, potential for more than minimal, widespreadF886Sep 14, 2022

  Based on observation, interview and record review the facility failed to ensure staff wore N95 face masks when testing residents for COVID-19. This applies to all residents residing in the facility. The findings include: The CMS 672 Resident Census and Conditions report dated September 12, 2022, shows, there is one resident residing in a certified bed in the facility. 1. On September 12, 2022, at 11:17 V5, V6, & V7 all lab technicians were testing residents on the skilled unit for COVID-19. They were wearing a KN95 face mask and not an N95 face mask. On September 13, 2022, at 9:59 AM, V3 Director of Nursing/Infection Preventionist stated, anyone testing residents for COVID-19 should be wearing an N95 face mask. They should not be wearing a KN95 face mask. […]

• No harm, potential for more than minimal, widespreadF812Dec 10, 2021

  Based on observation, interview, and record review, the facility failed to ensure the dishwasher temperature was checked prior to use, failed to ensure foods were covered and labeled when stored overnight and failed to remove leftover food from circulation after six days. This has the potential to affect all facility residents. The findings include: The facility's 12/7/21 Daily Census showed there were 57 residents in the facility. 1.On 12/7/21 at 9:30 AM, V5 Food Service Supervisor, accompanied this surveyor into the facility's kitchen. V7 dietary worker, was running the dishwasher. […]