Oaknoll Retirement Residence

In the surveyor’s words

From the most serious findings on record at Oaknoll Retirement Residence, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689Apr 4, 2024

  Based on observation, interview, policy review, and record review the facility failed to ensure neurological assessments were completed for residents with a known history of falls, and failed to ensure residents were safely transported via wheelchair for 6 of 21 residents reviewed for accidents (Residents #4, #8, #16, #21, #48, and #49). The facility reported a census of 57 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident#49 was unable to complete the Brief Interview for Mental Status (BIMS) exam due to short term and long term memory problems, inattention, and an altered level of consciousness. Section J of the MDS, Health Conditions, documented the resident had 2 falls since the prior assessment. […]

• No harm, potential for more than minimal, patternF761Apr 4, 2024

  Based on observation, interview, and facility policy review, the facility failed to maintain secure medication storage when 1 of 3 medication carts remained unlocked without staff supervision and further failed to keep schedule 4 medication (lorazepam concentrate solution) under double lock for 2 of 3 medication storage rooms observed. The facility reported a census of 57 residents. Findings include: On 04/01/24 at 02:14 PM, observation of the medication cart, located on South hallway, with the lock out in an unlocked position and keys hanging from the lock. The medication cart left unattended with four visitors and three residents sitting in the area, various ancillary staff also passed through the hallway. […]

• No harm, potential for more than minimal, isolatedF658Aug 28, 2024

  Based on observation, record review, staff interview, policy review and manufacturer insert review, the facility failed to provide services that met professional standards regarding medication administration for 2 of 2 residents observed (Resident #9 and #25). They did not have their insulin flex pen primed appropriately and the needle was not left under the skin after the insulin was injected for the recommended period of time to ensure the full dose of medication was given. The facility reported a census of 57 residents. Findings include: An observation on 8/26/24 at 7:59 AM, during the Medication Pass Task, revealed Staff A, Registered Nurse, (RN) administered Resident #9's insulin. […]

• No harm, potential for more than minimal, isolatedF655Apr 4, 2024

  Based on observation, record review, and interviews the facility failed to complete a baseline Care Plan within the first 48 hours of admission that addressed resident goals and services for 1 of 5 residents reviewed (Resident #48). The facility reported a census of 57. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #48 dated 1/31/24 revealed a Brief Interview for Mental Status (BIMS) could not be administered due to short term and long-term memory problems, disorganized thinking, and inattention. The MDS included diagnoses of hypertension, non-Alzheimer's dementia, and depressive episode. The MDS documented that the resident's most recent admit was 6/27/23. A Care Plan printed 4/3/24 at 2:35 PM included the revision history and documented an admitted [DATE]. […]

• No harm, potential for more than minimal, isolatedF657Apr 4, 2024

  Based on record review, observation, and interviews the facility failed to ensure the Care Plan was comprehensively reviewed, revised, or followed for 1 of 3 residents (Resident #35) reviewed for nutrition and for 1 of 3 residents (Resident #42) reviewed for behavioral health. The facility reported a census of 57 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 listed diagnoses of coronary artery disease, gastroesophageal reflux disease, and hypokalemia (low potassium). The MDS documented 3/2/23 as the residents most recent admitted . The MDS indicated the resident needed set up or clean up assistance with eating. […]