Treyton Oak Towers

In the surveyor’s words

From the most serious findings on record at Treyton Oak Towers, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 24, 2024

  Based on interview, record review, and review of the facility's video footage and policies, it was determined the facility failed to protect one (1) of seven (7) sampled residents (Resident #1) from neglect. On 01/26/2024 at approximately 7:50 PM, Resident #1 (R1) sustained a witnessed fall out of his/her wheelchair. R1 had a history of blood clots and had been receiving blood thinning medication (Eliquis, Plavix and Aspirin) prior to the fall on 01/26/2024. The resident sustained an injury to his/her head and right side of face. R1's nurse, Licensed Practical Nurse (LPN) #1 documented that she had notified the on-call physician and received orders to perform neuro checks per the facility's protocol, and to apply a cold pack to the affected area of the resident's face. […]

• Actual harm, isolatedF657Jun 24, 2021

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to revise the care plan timely with effective interventions to prevent recurring falls for one (1) of thirty-six (36) sampled residents, Resident #38. Record review revealed Resident #38 fell on [DATE], 04/21/2021, 05/03/2021 twice, 05/06/2021. Continued review revealed the care plan revisions did not occur timely and the resident fell again on 05/18/2021. The facility transferred Resident #38 to an acute care facility where the resident was diagnosed with a fractured clavicle. […]

• Actual harm, isolatedF689Jun 24, 2021

  Based on interview, observation, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to provide a safe environment for four (4) of thirty-six (36) sampled residents (Residents #2, #20, #38 and #108). The facility admitted Resident #38 with a known history of falls, and assessed the resident to be at high risk for falls and had poor cognitive memory. Resident #38 had five (5) falls in four (4) weeks. Staff educated the resident, who had poor cognitive memory, to remember to use the call light to call for the immediate intervention with the fall. The resident had a fall on 05/06/2021. […]

• No harm, potential for more than minimal, widespreadF726Jun 24, 2021

  Based on interview and record review it was determined the facility failed to ensure nursing staff had appropriate competencies and skill sets upon hire and annually to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Record review revealed the facility failed to document orientation/competency assessments. The findings include: Review of the facility's policy, Competency of Nursing Staff, revised October 2017, revealed all nursing staff must have met the specific competency requirements of their respective licensure and certification. […]

• No harm, potential for more than minimal, widespreadF812Jun 24, 2021

  Based on observation, interview and review of facility policy, it was determined the facility failed to serve food in a sanitary manor. Observations during the survey revealed dietary staff cross contaminated food with improper hand hygiene during meal services. In addition, wash/rinse temperatures and sanitization chemical levels were not documented. The findings include: Review of the facility's policy titled, Environmental Sanitation/Infection Control, revised 2014, revealed pathogenic organisms could be transferred to hands from a variety of sources and then moved from hand to food during preparation and service. […]