Ascension Oaks: Immediate Jeopardy Lift Safety - LA

The laundry supervisor didn't know manufacturer guidelines for washing the fabric slings that support residents during transfers. She put them in a regular dryer without a delicate cycle, potentially weakening the material that holds patients suspended in mid-air.

Federal inspectors cited the facility for immediate jeopardy to resident health and safety on June 26, finding that staff violated basic protocols for equipment designed to prevent falls and injuries during transfers.

The housekeeping and laundry supervisor told inspectors on June 25 that after Vander-Lift slings were washed, they went into the facility's dryer. The dryer had no delicate cycle. She was unaware of manufacturer guidelines for drying the slings.

The regional director of operations said staff should follow manufacturer guidelines for laundering the lift slings. The administrator agreed but offered no explanation for why this wasn't happening.

A CNA supervisor told inspectors that staff were supposed to visually check the entire Vander-Lift sling for rips, holes, and loose threads before using it to transfer residents. If a sling was already under a resident before transfer, staff should move the resident and do a full visual inspection.

The administrator said staff should transfer residents according to manufacturer instructions. He knew the lift's caster brakes shouldn't be locked when a resident was raised with the lift.

But when inspectors asked for documentation showing that one nursing assistant was evaluated and deemed competent to transfer residents with a Vander-Lift, the CNA supervisor couldn't produce any evidence.

The facility failed to complete required sections of its facility-wide assessment, missing evaluations of staff competencies, physical environment and equipment, ethnic and cultural factors, and facility resources. The regional director of operations admitted on June 26 that the facility hadn't completed Section 3 of the assessment and had missed part 3 covering competencies, staff needs, equipment, and contracts.

Seven nursing assistants lacked required training on resident rights and facility responsibilities. Personnel records showed staff hired between 2014 and 2023 had no documented evidence of this mandatory training. The administrator said he couldn't produce documentation that the training was completed.

The same seven staff members also lacked training on Quality Assurance and Performance Improvement programs, infection control systems, and compliance and ethics requirements. The administrator repeatedly told inspectors he couldn't produce evidence of any of these required trainings.

Medical records contained inaccuracies that could affect patient care. Resident #32's electronic medication record showed confusing entries for diabetes management. On June 17, the record indicated the resident received 3 units of Novolog insulin for a blood glucose level of 173, but another entry showed 0 units administered with blood glucose documented only as "high" rather than the actual number.

The assistant director of nursing called the documentation inaccurate and said nurses should record actual blood glucose levels instead of writing "high" to ensure accurate records of the resident's condition.

Infection control lapses created unsanitary conditions. On June 23 at 9:18 a.m., inspectors found soiled linens on the floor of Resident #94's room with a urine odor present. The resident said she didn't want the soiled linen on the floor and that someone needed to pick it up.

A certified nursing assistant agreed the soiled linen shouldn't be on the floor. When inspectors asked the administrator about this violation, he said he was happy with the nursing assistant's response but would provide no further explanation.

The facility's systematic training failures extended across multiple regulatory requirements. Staff hired as early as 2014 and as recently as 2023 showed identical gaps in mandatory education. A CNA supervisor who had worked at the facility for nearly a decade lacked the same basic training as workers hired within the past year.

Federal regulations require nursing homes to ensure staff competency with mechanical lifts because these devices support residents who cannot bear their own weight during transfers. Improper use can result in falls, injuries, or equipment failure that drops residents to the floor.

Lift slings must be maintained according to manufacturer specifications because they bear the full weight of residents during transfers. Fabric degradation from improper laundering could cause tears or failures during use.

The administrator's repeated inability to produce training documentation suggests systemic failures in staff development and regulatory compliance. When inspectors asked for evidence of required training across multiple categories, the facility couldn't demonstrate that basic safety and care protocols had been taught to frontline staff.

Resident #94 remained in her room with soiled linens on the floor and a urine odor while staff acknowledged the problem but took no immediate action to resolve it.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Ascension Oaks Nursing & Rehab Center from 2024-06-26 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Ascension Oaks Nursing & Rehab Center
• Browse all LA nursing home inspections