Oak Park Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Oak Park Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF607Oct 11, 2021

  Based on interviews, record review, the facility failed to develop and implement written policies and procedures to prevented abuse and thoroughly investigate allegations of abuse for 3 of 7 residents (Residents #1, #3 and #15) reviewed for abuse, in that; 1. The Administrator and DON failed to report to HHSC, investigate after becoming aware of the following allegations: Resident #15 reported on 10/3/21 that LVN C withheld his pain medications, closed the door and isolated him against his wished, and yelled and used intimidation to prevent Resident #15 from using the call light which caused the resident to be fearful and experience anxiety. This was reported to an unknown nurse on the morning of 10/4/21 but was not reported to the DON, Administrator, or HHSC. […]

• Immediate jeopardy, isolatedF600Dec 6, 2024

  Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (R #2) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #2 to prevent an act of sexual abuse on 05/04/2024 by R#1. On 05/04/24 around 9:30 PM, R #1, intoxicated and aggressive, was not monitored and left unsupervised in his room for 15 minutes. R #1 left his room and was found at 9:45 PM by CNA C engaged in a sexual act with R#2 (non-consenting adult). R#1 had undressed R#2's top and engaged in sucking her breast. The non-compliance was identified as PNC. The IJ began 05/04/24 and ended 11/25/24. […]

• Immediate jeopardy, isolatedF684Nov 29, 2021

  Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 8 residents (Resident #1) reviewed for quality of care, in that; The facility failed to ensure Resident #1 received a wound vac or wound care for a surgical wound as ordered by a physician which resulted in re-hospitalization of the resident on 11/15/2021. These failures resulted in identification of Immediate Jeopardy (IJ) on 11/16/2021. […]

• Immediate jeopardy, isolatedF726Nov 29, 2021

  Based on observation, interview, and record review the facility failed to ensure the nursing staff had the competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 8 residents (Resident #1 and 2 of 16 staff (RN D and Wound Care Nurse) reviewed for competency, in that; 1. The facility failed to ensure RN D had the appropriate competencies to ensure appropriate care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] a. […]

• No harm, potential for more than minimal, widespreadF812Jul 14, 2021

  Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The 3-compartment sink was not maintanined in working condition. 2. The dish machine did not have the manufacturer's data plate. These deficient practices could affect all residents who ate from the kitchen and could contribute to food-borne illnesses. The findings were: 1. Observation on 07/13/21 at 09:59 a.m. revealed when Cook E added sanitizing water to the third compartment of the 3-compartment sink, the water started to drain out. Cook F said the water in the third compartment leaked out and when he fills it up, it will drain down to being half full in a short while. […]