Oak River Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 8, 2021

  Based on observation, interview and record review, the facility failed to provide safe smoking practices and supervision for three of three sampled residents (Residents 1, 2, and 3) as required per facility policy and resident assessments when: 1. Resident 1's smoking assessment did not reflect his abilities to safely smoke unsupervised. This failed practice resulted in Resident 1 dropping smoking materials on his clothing, catching fire to himself, requiring emergent transfer to hospital. Resident 1 sustained a major burn, level trauma 1 with wounds over 50 to 60% of his body area. Resident 1 died the following day. 2. Resident 2 did not wear a smoking apron, was dependent on staff for mobility, and had shortness of breath on exertion. 3. Resident 3 did not wear a smoking apron. […]

• No harm, potential for more than minimal, patternF689Mar 17, 2022

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance to prevent accidents, and appropriate post fall or post accident care for two of 5 sampled residents (Residents 19 and 81), with a history of falls, when: 1. Resident 19 had five falls within two-months. Neuro (neurological assessments include mental status, motor function, pupillary responses and vital signs) checks were not done according to the facility policy for any of the five falls (all of which were unwitnessed, or the resident hit her head), interventions in the care plan were not implemented during the fall on 1/12/22, post fall injuries sustained on 2/17/22, were not monitored according to the care plan, and the falls care plan was not updated with appropriate… […]

• No harm, potential for more than minimal, patternF697Apr 8, 2021

  Based on interview and record review, the facility failed to ensure the pain management plan of care was implemented for one of three sample residents (Resident 1) when assessments did not include the source of the pain and the Interdisciplinary Team (IDT- a group of disciplines that discus resident's healthcare needs) did not evaluate the effectiveness of the pain regimen. This had the potential for Resident 1's pain management goals to be unmet. Refer to F 689 Findings: A review of a facility policy titled, Pain Assessment and Management, revised October 2010, indicated pain management is a multidisciplinary care process that includes assessing for pain, identifying strategies for different levels and sources of pain, monitoring the effectiveness of interventions. […]

• No harm, potential for more than minimal, isolatedF760Jan 23, 2025

  Based on Interviews and record review, the facility failed to meet this requirement when Resident 1 was administered nitroglycerin without a physician ' s order. This was against the facility ' s policy and had the potential to contribute to a decline in Resdident 1 ' s health. Findings Resident 1 was admitted to the facility on [DATE] for diagnoses that included metabolic encephalopathy, (an imbalance of chemicals in the blood that can cause confusion and tiredness), morbid (life-threatening) obesity, muscle weakness, congestive heart failure (inability of the heart to return blood flow to the body), history of stroke, and hypertension (high blood pressure). […]

• No harm, potential for more than minimal, isolatedF645Dec 5, 2024

  Based on interview, record review, facility document, and facility policy review, the facility failed to ensure residents' Preadmission Screening and Resident Review (PASARR) Level I Screenings were accurate for 2 (Resident #76 and Resident #111) of 3 residents reviewed for PASARR requirements. This had the potential for residents not to receive care and services in the most integrated setting appropriate to their needs and adversely affect their psychosocial and emotional well-being. Findings included: A facility policy titled, Pre-Admission Screening and Resident Review (PASARR), revised 10/2023, revealed, 1. […]