Oak Hollow of Georgetown Rehabilitation Center LLC

In the surveyor’s words

From the most serious findings on record at Oak Hollow of Georgetown Rehabilitation Center LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 18, 2021

  Based on observations, record review, interviews, and facility policy review, it was determined: 1. The facility failed to ensure a resident was safely transferred using the appropriate assistive devices identified in the facility's policy and/or residents' care plans. Resident #1 had a care plan to be transferred with a Hoyer (mechanical lift). Resident #1 was transferred using stand and pivot, which resulted in the resident sustaining a [MEDICAL CONDITION] tibia. This deficient practice affected one of three residents (Resident #1). 2. The facility failed to ensure nursing staff had access to gait belts to ensure residents got the required support needed during transfers. […]

• Immediate jeopardy, isolatedF684Aug 15, 2024

  Based on record reviews, review of personnel files, interviews, and policy review, the facility failed to ensure care and services were provided in accordance with professional standards for 1 (Resident (R)77) of 3 closed records reviewed. Specifically, the facility failed to ensure nursing staff followed a resident's code status and physician order. The nursing staff performed Cardiopulmonary Resuscitation (CPR) on R77, even though the resident had selected Do Not Resuscitate (DNR). […]

• Immediate jeopardy, isolatedF835Aug 15, 2024

  Based on record review, document review, job description review, staff interview and facility policy review, the facility Administrator failed to implement her job description to ensure the correct clinical operations related to resident's code status was followed. There is a potential for serious adverse outcomes because of the facility providing cardiopulmonary resuscitation (CPR) to a resident without confirming the code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes for 1 of 1 resident (Resident (R)77) reviewed. […]

• Immediate jeopardy, isolatedF867Aug 15, 2024

  Based on record review, document review, staff interview, and facility policy review, the facility failed to take an adverse event to Quality Assurance and Performance Improvement (QAPI) for corrective action, specifically, on [DATE], facility nursing staff administered cardiopulmonary resuscitation (CPR) to 1 of 1 resident (Resident (R)77) who had a Do Not Resuscitate (DNR) order in the electronic medical record (EMR). There is a potential for serious adverse outcomes because of the facility providing CPR to a resident without confirming code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes not being honored. […]

• No harm, potential for more than minimal, widespreadF847Aug 15, 2024

  Based on document review and interview, the facility failed to ensure the Addendum One-Arbitration Agreement located in the facility's admission packet contained all the fundamental requirements particularly indicating admission to the facility was not predicated on the resident signing the agreement and that the resident had thirty days to rescind the decision to sign the agreement. This failure has the potential to cause negative legal ramifications for all residents that signed the agreement due to the agreement not containing the regulated information. Findings include: Review of the undated facility Addendum One- Arbitration Agreement revealed the agreement did not contain information stating the resident did not have to sign the agreement for them to be admitted to the facility. […]