Inspection Results » The Oaks at Forest Bay

Health Inspection on March 11, 2019 ^[1]

1. Isolated: Immediate jeopardy to the resident health or safety

   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-04-22)

2. Pattern: Actual harm that is not immediate jeopardy

   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2019-04-22)

3. Isolated: Actual harm that is not immediate jeopardy

   • Ensure that residents are free from significant medication errors. (Corrected 2019-04-22)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-04-24)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-04-24)

4. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. (Corrected 2019-04-22)
   • Provide and implement an infection prevention and control program. (Corrected 2019-04-22)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-04-22)
   • Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. (Corrected 2019-04-22)

5. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide activities to meet all resident's needs. (Corrected 2019-04-22)
   • Respond appropriately to all alleged violations. (Corrected 2019-04-22)
   • Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (Corrected 2019-04-22)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-04-22)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-04-22)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-04-22)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-04-22)
   • Honor the resident's right to organize and participate in resident/family groups in the facility. (Corrected 2019-04-24)
   • Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (Corrected 2019-04-22)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-04-22)
   • Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. (Corrected 2019-04-22)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2019-04-22)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2019-04-22)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2019-04-22)

6. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide or obtain dental services for each resident. (Corrected 2019-04-22)
   • Post nurse staffing information every day. (Corrected 2019-04-22)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2019-04-22)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2019-04-24)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-04-24)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-04-22)
   • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected 2019-04-22)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2019-04-24)
   • Give the resident's representative the ability to exercise the resident's rights. (Corrected 2019-04-22)
   • Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is ne (Corrected 2019-04-24)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2019-04-22)
   • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (Corrected 2019-04-22)
   • Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. (Corrected 2019-04-22)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2019-04-22)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2019-04-22)