Oakland Heights

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jul 26, 2022

  Licensure Reference Number: 175 NAC 12-006.11E Based on observation and interviews, the facility failed to ensure hand hygiene was completed between touching surfaces and preparing food to prevent the potential for food borne illness. This had the potential to affect all residents that eat food from the facility kitchen. The facility census was 38. Findings are: Observation on 07/25/22 at 9:17 AM revealed Cook B removed a baking tray from the rack and placed it on the table, covered the bottom of the tray with aluminum foil and opened the refrigerator door and obtained the bowl containing washed sweet potatoes. Cook B obtained the spray butter and sprayed the tray. Cook B was observed placing the sweet potatoes on the tray and without performing hand hygiene. […]

• No harm, potential for more than minimal, widespreadF880Jul 26, 2022

  Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review, the facility failed to ensure that staff donned specific Personal Protective Equipment (PPE), failed to ensure laundry carts were sanitized per manufacture's recommendations, failed to ensure Resident 21's Positive Airway Pressure (PAP)(a machine that delivered positive airway pressure to a resident's airway to prevent the airway from closing) mask was cleaned daily and the [CONDITION(S)] filter was cleaned monthly, and failed to ensure hand hygiene was preformed between resident medication administration for 3 Residents (Resident 40,15, and 31). This had the potential to affect all residents in the facility. Total census was 38. Findings are: A. […]

• No harm, potential for more than minimal, patternF582Jul 26, 2022

  Based on interview and record review, the facility failed to ensure that the Advanced Beneficiary Notices (ABN)(a notice given to a resident to inform the resident of charges that Medicare will not cover) included all items, services, and cost information for 3 (Residents 20, 29, and 35) out of 3 sampled residents. Total census is 38. Findings are: A. A record review of the facility's un-dated Notice of Medicare Non-Coverage Policy revealed an ABN is the notice the facility used to notify a resident of the potential shift of financial liability to the resident for non-covered Medicare Part B items and services. […]

• No harm, potential for more than minimal, isolatedF628Jun 12, 2025

  Licensure Reference Number 175 NAC 12-006.09(G)(ii) Based on record review and interview, the facility failed to ensure that a discharge summary was completed for 1 resident (Resident 89) when they transferred to hospital via the emergency department. The facility had a census of 36. Findings are: A record review of Resident 89's nursing progress note dated 5/27/2025 revealed the resident required SLOC (Skilled Level Of Care - a level of care requiring the expertise and supervision of licensed health care professionals such as nurses and therapists) secondary to (due to) post colostomy placement (a surgical procedure connecting the colon to the outside of the body, allowing stool to exit) secondary to bowel obstruction (a condition in which digested material is prevented from passing… […]

• No harm, potential for more than minimal, isolatedF580Aug 15, 2023

  LICENSURE REFERENCE NUMBER 175 NAC ,d+[DATE].04c3A(6) Based on interview and record review, the facility failed to ensure the Resident Representative had been notified of a change in condition related to the active dying process for 1 of 1 sampled resident (Resident 92). The facility census was 37. Findings Are: A record review of the facility policy titled Change in a Resident's Condition or Status, with a revision date of [DATE], revealed the following; -A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting) and impacts more than one area of the resident's health status. […]