Oakland Manor Nursing and Rehabilitation Center LL

In the surveyor’s words

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

• Actual harm, isolatedF692Feb 24, 2022

  Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight loss for three (R6, R8, and R12) of four residents reviewed for nutrition, resulting in significant and/or severe weight loss and the potential for further clinical compromise. Findings include: According to the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss dated 2/24/22, .The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe .3 months - 7.5% weight loss is significant;… […]

• No harm, potential for more than minimal, widespreadF761Jan 28, 2026

  Based on observations, interviews, record review the facility failed to ensure medication and treatment supplies were secured to prevent unauthorized access, as evidence by an unlocked treatment cart accessible in-patient care area. Findings include:On 1/26/26 at 8:44 AM, the facility medication treatment cart was observed unlocked and unsecured across from the nurse's station. On 1/26/26 at 9:18 AM, the medication treatment cart was observed unlocked. Nurse E was interviewed and asked should the treatment cart be locked, Nurse E reported yes and proceeded to lock the cart. On 1/26/26 at 1:32 PM, the facility's medication treatment cart was observed unlocked and unsecured across from the nurse's station. […]

• No harm, potential for more than minimal, widespreadF925Oct 30, 2024

  Based on observation, interview, and record review, the facility failed to maintain a pest free environment. This deficient practice had the potential to affect all residents in the facility. Findings include: On 10/29/24 at 9:00 AM, during a tour of the kitchen serving area with Dietary Manager G, there was standing water and cobwebs observed in the corner under the steam table. Several gnats were observed near the standing water and flying about the kitchen area. When queried, Dietary Manager G stated the water was from filling the wells of the steam table. […]

• No harm, potential for more than minimal, widespreadF812Feb 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure the use of hair and beard restraints by kitchen staff, failed to ensure food items were covered, labeled, and dated, and failed to ensure potentially hazardous food items were held at the proper temperature. These deficient practices had the potential to affect all residents that consume food from the kitchen. Findings include: During an initial tour of the kitchen on 2/22/22 from 8:50 AM-9:30 AM, the following items were observed: Dietary Staff I was observed at the steam table inside the kitchen and was not wearing a hair restraint. When queried, Dietary Staff I confirmed she should have been wearing a hair restraint. […]

• No harm, potential for more than minimal, widespreadF867Feb 24, 2022

  Based on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program that identified deficiencies, and then developed and implemented appropriate plans of action to correct quality deficiencies related to weight monitoring for residents with weight loss. This deficient practice has the potential to affect all residents that resided in the facility. Findings include: During an interview on 2/24/22 at 1:35 p.m., when asked if the QAPI program had identified that there was a problem with resident weights not being completed timely, the NHA stated that the CDM (Certified Dietary Manager) will request weights sometimes in the meeting, but it was not identified as a problem and there was no process for improvement of… […]