Every finding on record at The Oaks at Jamestown

Based on observation, interview, and record review, the facility failed to ensure complete and accurate medical records for three residents (R8, R18, and R14) of seven residents reviewed for accurate medical records. Findings include: R14 Review of a Face Sheet revealed R14 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and surgical aftercare following surgery on the skin removing left ankle mass. In an observation and interview on 7/13/2026 at 11:19 AM on the outside patio, R14's left foot and ankle were wrapped with an intact dressing. R14 reported she had recent surgery to remove a mass from her ankle. Review of R14's weekly left ankle wound measurements in the Electronic Medical Record (EMR) as follows:5/22/2026- length 7.5cm, width 5.6cm, no depth documented6/10/2026- length 7.5cm, width 5.6cm, no depth documented6/17/2026- length 7.5cm, width 5.6cm, no depth documented6/24/2026- length 7.5cm, width 5.6cm, no depth documented7/1/2026- length 7.5cm, width 5.6cm, 0.3cm depth7/8/2026- length 7.5cm, width 5.6cm, no depth documented In an interview on 7/14/2026 at 10:11 AM, Assistant Director of Health Services (ADHS) A reported he was the facility wound nurse and responsible for weekly wound measurements and documentation. Weekly measurements of R14's left ankle wound were reviewed, and ADHS A reported he could not find left ankle wound depth for wound measurements on 5/22/2026, 6/10/2026, 6/17/2026, 6/24/2026, or 7/8/2026. ADHS A reported the wound was healing and was much deeper than 0.3cm after surgery but acknowledged that he could not prove this from documentation currently in the EMR. ADHS A reported he measured the depth of the wound weekly but routinely forgot to document the wound depth as the form used for wound documentation in the EMR did not have a space for wound depth and he was required to use the comments section to document this. ADHS A reported wound depth was important to determine whether a wound was healing, stalled, or worsening. Review of facility policy/procedure Guidelines for Wound Rounds, revised 5/10/2027, revealed .Wound Measurement forms should be monitored 5 days a week. to ensure weekly measurements and proper documentation is in place. Review of facility policy/procedure Guidelines for General Wound and Skin Care, revised 2/23/2023, revealed .Document type of wound, location, stage (if applicable), length, width, depth in centimeters. The information you enter into a patient's individual medical record communicates within the patient's integrated health records the type and frequency of patient care delivered and provides accountability for the care you implemented. This information is then available for all members of the health care team in all settings to review. It is necessary to document all the nursing care you provide for each patient, including assessment data, nursing problems or diagnoses, interventions, and evaluation of patient responses, in the health record. Your data enables providers and outside reviewers of the medical record to track a patient's clinical course. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 365). Elsevier Health Sciences. Kindle Edition. R8 Review of the medical record Electronic Medical Record (EMR) reflected R8 originally admitted to the facility 11/13/2024 with diagnoses that included paraplegia (motor or sensory impairment of the lower half of the body) and diabetes mellitus. Review of the Doctor's Orders for R8 reflected the Resident was scheduled regular appointments every two weeks at a wound clinic and received dressing changes to wounds on the buttocks every other day at the facility. On 7/13/2025 at 10:20 AM an interview was conducted with R8 in his room. R8 reported he had chronic wounds on his buttocks and that he travels to a wound clinic every other Monday (every two weeks) for care and treatment. Review of the EMR for R8 reflected treatment documentation from the wound clinic on 1/5/2026, 2/16/2026, and 4/28/2026. The medical record reflected treatment documentation of only these three encounters despite appointments every other week. On 7/14/2026 at 1:37 PM an interview was conducted with the wound care registered nurse (RN) A. RN A acknowledged the absence of documentation from the wound clinic despite regularly scheduled encounters. On 7/14/2026 at 10:18 AM an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked about the lack of documentation in the medical record of the encounters of R8 with the wound clinic. The DON reported the wound clinic did not provide documentation of treatment encounters unless care orders had changed. The DON reported she had asked the resident to request documentation when at the wound clinic wound but that R8 had never returned with the documentation of wound care encounters. R18 Review of the Electronic Medical Record (EMR) reflected R18 admitted to the facility 6/20/2026 following hospitalization for surgical repair of a hip fracture. Review of the EMR Progress Notes for R18 reflected on 7/10/2026 the Resident was transported to the hospital for an unrelated issue and returned to the facility on 7/12/2026. The Progress Notes reflected an entry on 7/14/2026 at 3:52 AM that three bruises on the left and right extremities had been identified and measured (bruise #1 – 6 centimeters (cm) x 8 cm, bruise #2 – 2 cm x 8 cm, bruise #3 – 2cm x 6cm). The documentation reflected that R8 admitted with bruises from the hospital two days prior. Review of the medical record EMR did not reveal in an admission assessment or other documentation that the bruises had been identified when R18 returned from the hospital on 7/12/2026. On 7/14/2026 at 9:43 AM an interview was conducted with the Director of Nursing (DON) in her office. The DON acknowledged the Progress Notes documentation of the bruises on 7/14/2026 but was unable to find any prior documentation the bruises after R8 returned from the hospital. The DON indicated the bruises should have been documented when R8 returned from the hospital on 7/12/2026.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 3 residents (R3, R57, & R58) out of three residents reviewed for EBP.Findings include:During an observation on 7/13/2026 at 9:15 AM, the 100 hall was observed. No evidence of Personal Protective Equipment (PPE) was noted outside any of the residents' rooms. During an observation on 7/13/2026 at 11:30 AM, movable towers of PPE were noted outside the rooms of three residents (R3, R57, R58). During an interview on 7/13/2026 at 11:40 AM, Licensed Practical Nurse (LPN) D reported the PPE had been placed for residents who required EBP because it had not been there previously. Resident #3 (R3)Review of a Resident Face Sheet reflected R3 admitted to the facility for aftercare following a stroke and received nutrition through a feeding tube. During an interview on 7/13/2026 at 11:37 AM, R3 reported that staff did not don a gown or gloves when providing care. Review of a Care Plan initiated on 06/01/2026 reflected R3 required EBP during high contact cares related to the presence of a feeding tube. The Goal of the plan of care was to minimize the risk for transmission of infection. Interventions included, Utilize gown and gloves per EBP policy during indwelling device care (e.g. central lines, urinary catheter, feeding tube, and tracheostomy).Review of a Medication Administration History dated 7/01/2026 - 7/15/2026 reflected the order Staff to use enhanced barrier precautions, wearing a gown and gloves at minimum during high-contact care activities. Start/End Date 5/27/2026 - Open Ended. According to the document, licensed staff were documenting staff were adhering to EBP each shift every day in July, despite there not being PPE in place prior to mid-morning on 7/13/2026. Resident #57 (R57)Review of a Face Sheet reflected R57 admitted to the facility on [DATE] with diagnoses that included a need for assistance with personal care. During an interview on 7/10/2026 at 9:15 AM, R57 reported that she had just admitted to the facility after a surgical procedure to replace her knee joint and had a surgical incision. Review of R57's Medication Administration History for the month of July, 2026 reflected an order for staff to use EBP was not initiated until 7/13/2026, three days after R57 admitted to the facility. Resident #58 (R58)Review of a Face Sheet reflected R58 admitted to the facility on [DATE] with diagnoses that included a need for assistance with personal care. During an interview on 7/13/2026 at 9:45 AM, R58 reported that they had recently been admitted to the facility for rehabilitation related to complications of a surgical procedure. Review of R58's Medication Administration History for the month of July, 2026 reflected an order for staff to use EBP was not initiated until 7/13/2026, three days after R57 admitted to the facility. During an observation on 7/14/2026 at 7:52 AM, an unknown Certified Nurse Assistant (CNA) and LPN D were observed completing a transfer with R58. LPN D and the CNA did not don any PPE for the high contact activity. During an interview on 7/14/2026 at 8:00 AM, LPN D was asked if they knew R58 required EBP. LPN D said they did know EBP was required and did not have an explanation for why the transfer was completed without the appropriate PPE. Review of the facility Enhanced Barrier Precautions (EBP) Standard Operating Procedure last reviewed 12/3/2025 reflected Enhanced Barrier Precautions (EBP) will be in place during high-contact care activities for residents with the following conditions: a. Residents at an increased risk of MDRO acquisition which include: i. All Residents with chronic wounds, including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. All Residents with indwelling medical devices 1. Includes but not limited to: catheters, central lines, feeding tubes, tracheostomy tubes. A peripheral intravenous line is not considered an indwelling medical device for the purpose of EBP. b. Residents known to be infected or colonized with a MDRO 2. Personal Protective Equipment (PPE) should be used even if blood and body fluid exposure is not anticipated. a. At minimum, staff shall wear gloves and gowns during high-contact care activities. May include face protection if splashes or sprays are anticipated during care. 3. High-contact care activities include but are not limited to: morning and evening ADL care, toileting, and showers. Includes transfers when bundled together with other high-contact activity which does not typically include transfers in common areas such as dining or activity rooms but would be included in therapy gym/treatment.

Based on observation, interview, and record review, the facility failed to assess one resident (R49) of two residents reviewed for self-administration of medication.Findings include:Review of a Face Sheet revealed R49 admitted to the facility on [DATE] with pertinent diagnoses which included gastro-esophageal reflux disease and heart failure. Review of R49's Physician's Orders revealed an active order started 1/29/2025 for Gas Relief (simethicone) tablet, chewable, 125mg, take twice a day.In an observation and interview on 7/13/2026 at 9:36 AM in R49's room, a round white pill was visible in a medication cup on the table next to R49 and within reach with no staff present. R49 reported this was her acid medication, which staff left for her on the bedside table.Review of R49's Electronic Medical Record (EMR) on 7/13/2026 revealed no documented assessment or Physician order that R49 had been determined to be safe to self-administer medication.In an interview on 7/14/2026 at 10:05 AM, Assistant Director of Health Services (ADHS) A reported R49 had not been assessed to determine whether she was safe to self-administer medication prior to 7/13/2026 when the medication was left by staff on her bedside table, and there was no Physician order for her to self-administer medication.Review of facility policy/procedure Guidelines for Self-Administration of Medications, revised 5/22/2018, revealed .The purpose of this policy is to. ensure the safe administration of medication for residents who request to self-medicate or when self-medication is a part of their plan of care. Residents requesting to self-medicate. shall be assessed. Results of the assessment will be presented to the physician for evaluation and an order for self-medication.