Oak Manor Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Oak Manor Healthcare & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF925Jan 25, 2024

  Based on observations, staff interviews and facility file review, the facility failed to ensure an effective pest control program to include one of one kitchen space, and during two of four days observed (1/22/2024 and 1/24/2024). Findings included: On 1/22/2024 at 10:34 a.m. during an initial kitchen tour there were seven to eight black in color small flying insects observed flying around the area. The flying insects were observed flying around the sink wall, around and near the parked meal tray carts, around and near the S plastic water drain pipe under the sink, as well as at, near and under the dish washing machine, specifically near the floor drain. […]

• No harm, potential for more than minimal, patternF641Jan 25, 2024

  Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for three (#126, #127, and #128) of three records reviewed, related to discharge. Findings included: 1. Review of the clinical record for Resident #126 revealed admission to the facility on [DATE] and discharge on [DATE] as per the face sheet. Further review of the Progress notes dated [DATE] revealed the resident was in respiratory distress. Orders were received, the family was notified, and the resident was sent out of the facility to [name of hospital] for further assessment and treatment. Review of the MDS assessment dated [DATE] revealed: Section A, Part F: Death in Facility. Section A, Part A2000: discharge date - [DATE]. […]

• No harm, potential for more than minimal, patternF755Sep 18, 2023

  Based on observation, interview, and record review, the facility failed to maintain a system of records to accurately account for all controlled medications in one of three medication carts inspected for six (Resident #2, #5, #6, #7, #8, and #9) of 15 sampled residents. Findings included: An inspection of a medication cart was conducted on 9/18/2023 at 1:00 PM on the Central Wing of the facility with Staff A, Registered Nurse (RN). Staff A was observed at the unit nurse's station with the medication cart's controlled medication log. Staff A stated she was in the process of signing out the controlled medications she administered to residents during the morning medication pass. […]

• No harm, potential for more than minimal, isolatedF584Jan 27, 2025

  Based on observations, interviews, and record review, the facility failed to ensure resident walls and ceiling tiles were maintained in a clean, sanitary, and homelike environment for three resident rooms (224, 225, and 226) out of three rooms observed on the central wing. Findings included: An observation was conducted on 1/27/25 at 9:50 AM of room [ROOM NUMBER]. There was peeling paint behind both beds in the room and missing paint on the wall near the bathroom door. Behind bed A there was missing paint with exposed wood that was shredded. The air vent was observed to be against a ceiling tile and where the ceiling tile and the air vent meet there was a black and rust-like discoloration on the ceiling tile. […]

• No harm, potential for more than minimal, isolatedF656Jun 5, 2024

  Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan related to wound care orders for one (Resident #1) of three sampled residents. Findings included: Resident #1 was admitted on [DATE] and discharged on [DATE]. Admission record showed diagnoses included but not limited to spinal stenosis lumbar region, spondylolisthesis lumbar region, low back pain, abnormalities of gait and mobility, and peripheral vascular disease. Review of orders showed offload heels often in bed as tolerated and skin prep heels every shift and wound consult for evaluation and treatment for issues identified. Review showed the physician orders to perform left dorsal wound care was not on the physician orders. […]