West Oaks Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF760Feb 11, 2025

  Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. 1. The facility failed to discontinue Resident #1's metformin and glyburide medications. 2. The facility failed to implement blood sugar monitoring for Resident #1. 3. […]

• Immediate jeopardy, isolatedF689Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #2) of three residents reviewed for accidents and hazards, in that: The facility failed to ensure Resident #2 (who was a high-elopement risk) did not elope from the facility on 03/26/24 at 12:50 PM when the Receptionist used her remote-control door opener to unlock the front door. He was located over 24 hours later at a bus stop approximately 12 miles from the facility. The noncompliance was identified as PNC. The IJ began on 03/26/24 and ended on 03/27/24. […]

• Immediate jeopardy, isolatedF689Sep 3, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 4 residents (Resident #72) reviewed for accident hazards and supervision, in that; 1.Resident #72 had 2 unauthorized, unchaperoned elopement events on 10/03/2022 and 01/03/2023, without the facility providing adequate safety interventions to prevent further elopement risks. An IJ was identified on 09/01/2023. The IJ template was provided to the facility on [DATE] at 05:30 PM. […]

• Immediate jeopardy, isolatedF600Dec 12, 2022

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of 15 residents reviewed for resident-to-resident abuse. The facility failed to prevent Resident #2, who had a history of hypersexual behaviors, from touching Resident #1 in a sexually inappropriate manner on 12/04/2022. LVN B failed to identify Resident #2's unwanted touching of Resident #1's breast area as sexual abuse. The facility failed to protect Resident #1, who had a history of sexual assault as a child, from being sexually abused by Resident #2. These failures placed Resident #1 at serious risk of reliving trauma, mental anguish, decreased psychosocial well-being and mental health, and increased anxiety. On 12/09/2022 at 5:40 p.m. […]

• Actual harm, patternF697Apr 10, 2024

  Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #3 reviewed for pain management. The facility failed to ensure Resident #3 received his 08:00 AM scheduled Norco on time for 7 of 10 days between 04/01/24 and 04/10/24. This failure placed residents at risk of increased pain and decreased quality of life. Findings included: Review of the undated face sheet for Resident #3 reflected a [AGE] year-old male admitted to the facility on [DATE]. […]