West Oaks Senior Care & Rehab Center

In the surveyor’s words

From the most serious findings on record at West Oaks Senior Care & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Jul 27, 2023

  Based on record review and interview the facility failed to consistently ensure the services of a Registered Nurse (RN) for eight consecutive hours per day, seven days per week, resulting in the potential for unmet care needs for all residents who reside in the facility. Findings include: Review of master schedules provided for Registered Nurse (RN) coverage for the past 60 days revealed, the facility did not have eight consecutive hours of RN coverage on the following days: Saturday: 6/10/23 Saturday: 6/24/23 Sunday: 6/25/23 Saturday: 7/1/23 Sunday: 7/2/23 Monday: 7/4/23 Sunday: 7/9/23 In an interview on 7/27/23 at 12:51 p.m., the Director of Nursing (DON) reported they did not have an RN everyday. […]

• No harm, potential for more than minimal, widespreadF908Jul 27, 2023

  Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility reach-in freezer which had the potential to affect all residents that eat from the kitchen. Findings include: During the initial tour of the kitchen on 7/24/2023 beginning at 8:54 AM with Dietary Manager (DM) F the internal temperature of the reach-in freezer was observed to be 20 F (Fahrenheit). A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. DM F said the temperature of the freezer should be zero or below. A review of a facility policy titled, Food Storage, received during the survey, documented in part the following, Frozen foods must be maintained at a temperature to keep the food frozen solid. […]

• No harm, potential for more than minimal, widespreadF812May 26, 2022

  Based on observation, interview, and record review, the facility failed to ensure food preparation and service equipment were adequately cleaned and allowed to air dry. This deficient practice had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: During a return observation of the kitchen on 5/24/2022 at 2:45 PM, Dietary Aide (DA) M was observed using a cloth towel to hand dry cleaned and sanitized meal trays in the dish tank area and DA N was observed using a cloth towel to hand dry cleaned and sanitized pots and pans near the three-compartment sink. […]

• No harm, potential for more than minimal, widespreadF908May 26, 2022

  Based on observation, interview, and record review, the facility failed to ensure equipment used in food service operation was maintained in a safe and sanitary operating condition, resulting in this food equipment not being protected against contamination from sewage or other sources of contamination, potentially affecting all residents in the facility consuming ice from the kitchen ice machine. Findings include: During the initial tour of the kitchen on 5/24/2022 at 9:00 AM with Dietary Director (DD) I, the drain line from the ice machine was observed lying on the floor drain. The ice machine was not equipped with the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line of the ice machine and the flood rim of the floor drain). […]

• No harm, potential for more than minimal, patternF880Dec 5, 2023

  This citation pertains to #MI00140569. Based on interview and record review, the facility failed to ensure two residents (R107 amd R108) out of four residents reviewed for infection control, received proper COVID-19 testing following a COVID-19 outbreak in the facility, resulting in the potential for spread of COVID-19 throughout the building. Findings include: It was reported to the State Agency that staff were not following proper infection control/prevention guidelines. On 12/5/23 beginning at 11:03 AM, Infection Preventionist (IP) G was queried about COVID-19 testing conducted in the facility following a recent COVID outbreak. IP G said the recent COVID-19 outbreak began on 10/6/23 when Resident #105 (R105) tested positive. […]