Oaks Health CTR at the Marshes of Skidaway Island

In the surveyor’s words

From the most serious findings on record at Oaks Health CTR at the Marshes of Skidaway Island, in the surveyor’s own words.

• Actual harm, isolatedF656Jan 19, 2025

  Based on interviews and record reviews, the facility failed to ensure that the care plan was followed for Activities of Daily Living (ADL) ensuring that care was provided by the appropriate number of staff, to prevent accidents, for one of 14 residents (R) (R115), sampled for care plans. Harm was identified to have occurred on 12/16/2024 when R115 fell while receiving ADL care, resulting in bilateral femoral fractures and a right humeral fracture. Findings include: A review of the undated facility policy titled Care Plans, Comprehensive Person-Centered revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. […]

• Actual harm, isolatedF689Jan 19, 2025

  Based on record review and staff interviews, the facility failed to protect one of two residents (R) (R115) sampled for falls during Activities of Daily Living (ADL) care. Harm was identified to have occurred on 12/16/2024 when R115 fell while receiving ADL care, resulting in bilateral femoral fractures and a right humeral fracture. Findings include: Review of the Electronic Medical Records (EMR) revealed an admitted [DATE] with a diagnosis of post-polio syndrome, cognitive impairment of unknown etiology, abnormal gait and mobility, hypertensive heart disease without heart failure, contracture right and left foot, and muscle weakness. […]

• No harm, potential for more than minimal, widespreadF880Jan 19, 2025

  Based on observation, staff interview, record review, and review of the facility policies titled Standard Precautions, Dressings, Dry/Clean, and Laundry Services, the facility failed to ensure infection control practices were adhered to during wound care for one of three residents (R) (R12) reviewed for wound care. The facility also failed to ensure laundry practices were conducted so as not to cause cross-contamination of clean linen with soiled linen. The deficient practices had the potential to increase R12's risk of infections due to cross-contamination during wound care and had the potential to place all residents residing in the facility at risk of infections due to cross-contamination due to inappropriate handling of linen. […]

• No harm, potential for more than minimal, patternF636Jul 7, 2022

  Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed annually and upon admission for three residents (R) (#3, #4 and #65) of 13 sampled residents. Findings include: 1. Review of R#3's MDS listings revealed that a Quarterly MDS with an Assessment Reference Date (ARD) date of 3/4/22 was the last MDS completed. 2. Review of R#4's MDS listings revealed that a Quarterly MDS with an ARD date of 2/24/22 was the last MDS completed. 3. Review of R#65's MDS listings revealed that an Entry MDS with an ARD date of 4/30/22 was the last MDS completed. […]

• No harm, potential for more than minimal, isolatedF554Jan 19, 2025

  Based on observations, staff and resident interviews, record review, and review of the facility policies titled Administering Medications and Self-Administration of Medications, the facility failed to ensure medications were not left at the bedside of two of 14 sampled residents (R) (R7 and R215) who were not assessed for medication self-administration. This deficient practice had the potential to place R7 and R215 at risk for the unsafe use of medications. Findings: Review of the facility policy titled Administering Medications, dated 2001, revealed the Policy Statement was Medications are administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included 27. […]