Oak Haven Assisted Living

The facility failed to ensure medications were administered according to physician orders. Specifically, for one resident, the facility administered 5 units of Fiasp FlexTouch insulin instead of the ordered 10 units when the resident's blood sugar was 263.

The facility failed to properly implement a pharmacy change order for Resident #5, which required transitioning from Novolog to Flastrep FlexTouch insulin. Specifically, staff administered incorrect insulin doses based on blood glucose readings, including an instance where 5 units were administered for a blood glucose of 220 when the order required 10 units for readings over 200. The medication administration record (MAR) showed a failure to monitor and follow the updated sliding scale instructions for several months.

The facility failed to ensure proper health care referral and follow-up for a resident following a fall. Specifically, despite hospital discharge recommendations, the facility did not arrange the required physical therapy and occupational therapy for the resident.

The facility failed to ensure proper health care referral and follow-up for a resident following a fall. Specifically, despite hospital discharge recommendations, the facility did not arrange the required physical therapy and occupational therapy services for the resident.

The facility failed to ensure health care referral and follow-up for a resident following a fall. Specifically, the facility did not arrange for the recommended physical therapy and occupational therapy services as advised in the hospital discharge summary. This oversight resulted in the resident continuing to experience shoulder pain and limited mobility without necessary therapeutic intervention.

The facility failed to ensure that staff responsible for personal care, supervision, and medication administration within the Special Care Unit (SCU) completed the required 20 hours of training specific to the SCU population. Specifically, a review of personnel files for sampled staff members revealed insufficient documentation of training beyond the initial six-hour orientation.

The facility failed to ensure that 4 out of 5 sampled staff members responsible for personal care, supervision, and medication administration within the Special Care Unit (SCU) completed the required 20 hours of training specific to the SCU population. Specifically, records for Staff A showed only 6 hours of orientation were completed with no documentation of the additional required training within six months of hire.