OAK CREST NURSING CENTER
LOCATED: 1902 FM 3036, ROCKPORT, TX 78382

OAK CREST NURSING CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS.

LEVEL OF HARM –IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure that three Residents, (R #1, R#4 and R#14), of 26 Residents reviewed for abuse and neglect, was free from neglect, in that:

-The facility staff did not follow R #4’s Physician order [REDACTED]. R#4’s oxygen concentrator setting was observed at 2 and 2.5 LPM on three occasions on [DATE]-[DATE], and during transfer to the shower room when R #4 was provided with no oxygen.

The facility did not ensure that R #14 wore her oxygen during ambulation, she became short of breath, and she fell, fracturing her right hip and hitting her head. The facility did not follow R #14’s Physician order [REDACTED]. R #14 expired on [DATE], in the facility.

The facility did not ensure R #4’s most current oxygen therapy order of continuous Oxygen at 3 liters per nasal cannula was accurate on her Treatment Administartion Record and the oxygen therapy was consistently monitored.

The facility did not ensure the oxygen tubings were changed weekly, as per the facility’s policy and oxygen concentrator filters remained clean for R #4, R #17, and R #19.

In an interview on [DATE] at 11:45 a.m., CNA E said on [DATE] she assisted R#14 out of her room to go to the shower room. CNA E said R#14 complained of being a little dizzy when she opened the shower room door and R#14 fell to the side. CNA E said R#14 fell right inside the shower room by the door. CNA E said R#14 said she was dizzy and could not breathe. CNA E said R#14 used her regular walker with a portable oxygen tank on it but she was not using oxygen when she was walking. CNA E said she had showered R#14 before and R#14 usually only needed help with washing her back and drying off. CNA E said R#14 usually had her portable oxygen on the other side of the wall from the shower and she wore the nasal canula in the shower. CNA E said R#14 told her she did not need her oxygen and sometimes did not wear her oxygen. CNA E said she was not given instructions about whether R#14 needed to wear her oxygen all of the time but she knew R#14 could not be left alone. CNA E said they just walked two doors down from R#14’s room to the shower room when R#14 fell.

In an interview at 10:10 a.m. on [DATE] with CNA E, when asked if she had asked R#14 to put her oxygen on before they walked down the hall toward the shower room on [DATE], CNA E said she did not ask R#14 to put on her oxygen because she did not want to pressure her to wear her oxygen. CNA E said sometimes R#14 wore her oxygen and sometimes she did not wear it.

In an interview at 10:20 a.m. on [DATE], the Assistant Director of Nurses (ADON), when asked how often R#14 wore her oxygen, said R#14 went without her oxygen sometimes and probably wore her oxygen about 50% of the time. The ADON said R#14 would go around the building without it sometimes. Surveyor asked the ADON if there was any change in R#14’s breathing and need for oxygen the week before she fell, and the ADON replied that she did not know of any change.

Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.