Oak Knoll Healthcare Center

Oak Knoll Healthcare Center

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Oak Knoll Healthcare Center? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Oak Knoll Healthcare Center

Oak Knoll Healthcare Center is a for profit, 123-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Maynard, Acton, Sudbury, Concord, Hudson, Wayland, Marlborough, Westford, Weston, Bedford, Southborough, Chelmsford, Clinton, Framingham, Lexington, and the other towns in and surrounding Middlesex County, Massachusetts.

Oak Knoll Healthcare Center
9 Arbetter Dr,
Framingham, MA 01701

Phone: (508) 877-3300
Website: http://www.whittierhealth.com/nursing_homes/oak_knoll.html

CMS Star Quality Rating

Oak Knoll Healthcare CenterThe Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Oak Knoll Healthcare Center in Framingham, Massachusetts received a rating of 3 out of 5 stars.

Performance Area Rating
Overall Rating 3 out of 5 (Average)
State Health Inspections 2 out of 5 (Below Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 3 out of 5 (Average)

Fines Against Oak Knoll Healthcare Center

The Federal Government fined Oak Knoll Healthcare Center $2,735 on 04/07/2017 for health and safety violations.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Oak Knoll Healthcare Center committed the following offenses:

 

Failed to make sure each resident receives an accurate assessment by a qualified health professional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to ensure the accuracy of the Minimum Data Set (MDS) Assessment relative to the resident interview for Brief Interview for Mental Status (BIMS) and Mood, and for Urinary Continence for 2 Residents (#7 and #17) in a total sample of 22 residents.

Findings include:

1. For Resident #7, the facility staff failed to ensure the accuracy of an Annual MDS Assessment and a Quarterly MDS Assessment relative to resident interviews for BIMS and Mood. Review of the MDS Manual indicates the resident interviews should be attempted if the resident is coded as understood, usually understood or sometimes understood. Resident #7 was readmitted to the facility in 1/2014 with [DIAGNOSES REDACTED]. Review of the 2/17/17 Annual and 5/12/17 Quarterly MDS Assessments, indicated the staff interviews were conducted for the BIMS and Mood. Both MDS Assessments indicated the resident had been coded as sometimes understood. During an interview on 6/8/17 at 1:40 P.M., the MDS Nurse said the resident interviews were not done and should have been attempted.

2. For Resident #17, the facility staff failed to accurately code the urinary continence on an Admission MDS. Resident #17 was admitted to the facility in 4/2017, with [DIAGNOSES REDACTED]. Review of the Initial Nursing Admission Assessment, dated 4/24/17, indicated that the resident was continent of bladder. Review of the Resident Care Card, undated, indicated that the resident was continent of bladder. Review of the Certified Nurse Aide Flow Sheet, dated (MONTH) (YEAR), indicated that the resident was continent of bladder. Review of the Incontinence Evaluation, dated 4/24/17, indicated that the resident was always continent of urine. Review of the 5/1/17 Admission MDS Assessment, indicated Urinary Continence was coded as not rated. During an interview on 6/9/17 at 10:15 A.M., the MDS Nurse said the Urinary Continence on the Admission MDS was miscoded and should have indicated urinary continence.

Failed to provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility staff failed to follow the written plan of care for two sampled resident (#2 and #5), in a total sample of 22 residents.

Findings include:

1. For Resident #5 the facility staff failed to follow a physician’s orders [REDACTED]. Resident #5 was admitted to the facility 3/2015 with multiple [DIAGNOSES REDACTED]. Review of the 3/15/17 Annual Minimum Data Set (MDS) Assessment indicated the resident was totally dependent for mobility and activities of daily living.

Review of the current signed Physician orders [REDACTED]. During an observation on 6/7/17 at 10:15 A.M., Resident #5 was lying in bed on an air mattress that was observed to be set at 10.1. During an observation on 6/7/17 at 2:05 P.M., the resident’s air mattress setting was 10.1. During an observation and interview with Nurse #1 on 6/8/17 at 7:45 A.M. she said the air mattress was set at 10.1 and should be set at 6. During an interview with the facility Staff Development Coordinator on 6/8/17 at 7:45 A.M. she said the resident’s air mattress should have been set at 6 per the Physician order [REDACTED].

2. For Resident #2, the facility staff failed to follow the plan of care relative to the use of a wheelchair tab alarm. Resident #2 was readmitted to the facility in 3/2017 with [DIAGNOSES REDACTED]. Review of the 3/15/17 Quarterly MDS Assessment, indicated the resident was cognitively intact as evidenced by a score of 13 out of 15 on the Brief Interview for Mental Status. Review of the Physician’s Interim/Telephone Orders, dated 3/25/17, indicated an order for [REDACTED]. Review of the Resident Care Card, undated, indicated the resident was to have a tab alarm in the chair. Review of the 6/2017 physician’s orders [REDACTED]. Review of the 6/2017 Treatment Sheets indicated, a tab alarm on wheelchair at all times while sitting in chair and to monitor function and placement every shift. During an observation on 6/6/17 at 1:45 P.M., the resident was sitting in a wheelchair, in his/her room. The resident was alert and oriented. The resident’s wheelchair did not have a tab alarm. During an observation on 6/7/17 at 11:30 A.M., the resident was sitting in a wheelchair, in his/her room. The resident’s wheelchair did not have a tab alarm. During an observation on 6/7/17 at 2:30 P.M., the resident was sitting in a wheelchair, in his/her room. The resident’s wheelchair did not have a tab alarm. During an observation and interview on 6/7/17 at 2:35 P.M. with Nurse #3, she said the resident did not have a tab alarm on the wheelchair but should have.

Failed to maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Based on observations and staff interviews, the facility staff failed to ensure that 2 medications were of current date to provide reliability of strength and accuracy of dosage for 2 residents.

Findings include:

Review of the Facility 6.0 General Dose Preparation and Medication Administration Policy, dated 12/01/07, indicated that prior to the administration of medication, facility staff should check the expiration date of the medication to be administered. a. During an inspection of the First Floor Long Term Care Unit Medication Room refrigerator, on 6/7/17 at 1:15 P.M., the surveyor observed a bottle of Ativan (an antianxiety medication) liquid, for a specific resident. Review of the pharmacy label on the Ativan bottle, indicated the prescription was filled by the pharmacy on 8/16/16.

Review of the Ativan manufacturer’s information listed on the packaging, indicated that once opened, it should be discarded after 90 days. Review of the Narcotic Book used by nursing, indicated the first dose of Ativan was administered on 8/17/16. Further review of the book, indicated the medication had been administered until 5/3/17. During an interview on 6/7/17 at 1:15 P.M., Nurse #1 said she was not aware that the Ativan liquid should have been discarded after 90 days once opened. b. During an inspection of the First Floor Long Term Care Unit Medication refrigerator, on 6/7/17 at 1:20 P.M., the surveyor observed one bottle of Ativan liquid, for a specific resident.

Review of the pharmacy label on the Ativan bottle, indicated the prescription was filled by the pharmacy on 5/5/16. Review of the Narcotic Book used by nursing, indicated the Ativan was administered in 5/2016. Further review of the book, indicated the medication had been administered until 4/7/17. During an interview, on 6/7/17 at 1:25 P.M., Nurse #2 said she was not aware the Ativan liquid should have been discarded after 90 days once opened.

Failed to have a program that investigates, controls and keeps infection from spreading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy and staff interviews, the facility staff failed to follow proper infection control practices regarding a) housekeeping and cleaning a resident room requiring isolation/precautions to prevent cross contamination and the potential spread of infection, and b) failed to follow infection control practices regarding the use of isolation/precautions to prevent cross contamination and the potential spread of infection for one sampled resident #5, in a total of 23 sampled residents .

Findings include:

Resident #5 was admitted to the facility 3/2015 with multiple [DIAGNOSES REDACTED]. Review of the 3/15/17 Annual Minimum Data Set (MDS) Assessment indicated the resident was totally dependent for mobility and activities of daily living. During an observation of the resident’s room on 6/6/17 at 1:00 P.M., 2 signs were adhered to the outside doorframe, one yellow and one orange, that directed all visitors to report to the nurses station before entering the resident’s room. There was a metal holder with multiple compartments hanging on the outside of the resident’s bedroom door that contained personal protective equipment (PPE), such as gloves and yellow precaution gowns. Review of the 6/2017 Physician orders [REDACTED]. During interview on 6/6/16 at 1:35 P.M., Nurse #2 said Resident #5 was on precautions for ESBL (Extended Spectrum Beta-Lactamase) in the urine and[DIAGNOSES REDACTED]icile infection in the intestines.

a) Review of the undated Facility’s Precaution Room Cleaning – Guidelines For Best Practice in use by the facility, indicated the following:

-Identify the isolation/precaution rooms on your unit.
-Cross reference the sign located on the outside of the bedroom door with the log book located at the nurses station.
-Don appropriate PPE.
-Put the mop heads and rags (if applicable) in a bag once floor disinfection is complete, tie bag and place in doorway on floor in the resident room.
-Request another staff member to transport all bagged disposable items to trash disposal site & all bagged mop heads/applicable rags to the laundry, this staff member stands outside the room with gloves donned, holding another bag in which housekeeper places already bagged items inside of. NOTE: staff member transporting items is not to go into the resident room at any point.
-Housekeeper to remove PPE, perform hand hygiene, then exit room. -Housekeeper is now to open housekeeping closet, change water solution in bucket & replace mop head before moving on to the next room

On 6/7/17 at 9:00 A.M., the surveyor observed Housekeeper #1 washing the floor in Resident #5’s room. She was observed to be wearing gloves but no other PPE. Housekeeper #1 was observed exiting Resident #5’s room with the wet mop. She placed the mop into the wash water bucket on the housekeeping cart. She was then observed pushing the cart to another resident room and entering the room with the same mop. The surveyor approached Housekeeper #1 when she was observed to enter the second room and asked her to explain the cleaning procedures used between a precaution and non-precaution resident room.

Housekeeper #1 proceeded to get another housekeeper to speak to the surveyor due to a language barrier. Housekeeper #2 and #1 indicated they were going to clean the non precaution room after the precaution room using the same mop head and water. The surveyor asked the Housekeepers to get their supervisor for verification of the process of cleaning resident rooms that require precautions to prevent cross contamination and the possible spread of infection. During an interview with the Environmental Services Director (ESD) on 6/7/17 at 9:10 A.M., he said they are supposed to clean the precaution rooms last, and are to change the water and the mop head after cleaning a precaution room before cleaning any other rooms. The ESD proceeded to speak to Housekeeper #1 and #2 in their primary language. During an interview with the the facility Staff Development Coordinator on 6/7/17 at 9:40 A.M., she said the signage outside Resident #5’s room was color coded indicating what type of infection the precautions are for, the yellow sign indicated a[DIAGNOSES REDACTED] infection and the orange sign indicated an ESBL infection. She further said all new staff are oriented to infection control including the requirements for precautions. Housekeeping staff participate in orientation.

b) Review of the Facility’s policy Guidelines for Patients with Resistant Organisms Including MRSA (Methicillin Resistant Staphylococcus Aureus), VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]), [DIAGNOSES REDACTED]icile and ESBL dated as revised 1/2016 indicated the following:

-Isolation precautions will be implemented based on the type of infection or colonization. Standard blood and body fluid precautions do NOT replace additional designated isolation precautions to prevent transmission and cross contamination of MRSA, VRE, [DIAGNOSES REDACTED]icile or ESBL.

-Gloves will be worn when providing care that involves personal contact.

-Gowns will be worn if the caregiver’s clothing is likely to have contact with the infected or colonized resident in the course of care. The Multidrug

-Resistant Organism for[DIAGNOSES REDACTED]icile dated as revised 8-2012 indicated the following for the use of gowns:

-Worn when providing direct care. -Worn when there is contact with secretions/excretions (changing linens).

-Worn when coming into contact with environmental surfaces that are likely to be contaminated.

-Gowns are to be removed and discarded prior to leaving the room. On 6/8/17 at 9:05 A.M., Nurse #2 was observed in Resident #5’s room on the left side of the bed applying a left hand splint with gloves on without a yellow precaution gown. Upon exiting the resident’s room the nurse said she had also had put on the resident’s boots (floating heel boots used to reduce pressure on the heels). During an interview outside of the resident’s room on 6/8/17 at 9:07 A.M., the Director of Nurses said Nurse #2 should have donned a gown in addition to gloves as required before providing direct care to the resident.

Oak Knoll Healthcare Center, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – Oak Knoll Healthcare Center

Inspection Report for Oak Knoll Healthcare Center – 06/09/2017

Page Last Updated: August 20, 2018

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