College Oak Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to provide written notice of bed hold policy upon transfer to one of three sampled residents (Resident 1). When Resident 1 was transferred to an acute care hospital and Resident 1's responsible party (RP) was not given a written notice of the facility's bed hold policy. This failure had the potential for Resident 1 and their RP to not be informed of their rights to return to the facility. A review of Resident 1's progress note dated 5/11/26 indicated, resident was sent to an acute care hospital for treatment via 911 as an emergency transfer. A review of Resident 1's Notice of Transfer/discharge date d 5/11/26 indicated, Resident 1's RP was notified via phone of the transfer. Notice indicated, [RP name] did not give concent [sic] for bed hold via phone. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner for a census of 112 when:1. Three bags of food were found unsealed in the freezer, and 2. There was a large buildup of black residue on the inside door jam of the walk-in refrigerator .These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals.

Inspectors wroteBased on interview and record review, the facility failed to notify a room change and to provide room transfer assessment for two of 112 sampled residents (Resident 32 and Resident 127) when Resident 127 was moved into Resident 32's room. These failures resulted in both Resident 32 and Resident 127 to be inadequately informed regarding the transfer and did not receive complete assessments following the room change.

Inspectors wroteBased on interviews, observations, and record review the facility failed to manage pain for two of 24 sampled residents (Resident 3 and Resident 136), when Resident 3 and Resident 136 reported significant pain to staff and did not receive their ordered pain medication when requested. This failure led to prolonged pain for Resident 3 and Resident136.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the accepted professional principles and current standard of practice for a census of 112 when an over the counter medication was found stored out of its original package. These failures had the potential for residents to receive medications that were expired and with unsafe or reduced potency.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate medical records for one out of 13 sampled residents when Resident 12's Medication Administration Record (MAR, a legal document that list administered drugs) was inaccurate and inconsistent with the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident). This failure placed Resident 12 at risk for medication errors, adverse drug reactions and ineffective drug therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and appropriate discharge was provided to one of three sampled residents (Resident 1), when Resident 1 was not permitted admission to the facility upon return from a day leave and was discharged to her car. This failure resulted in Resident 1's unanticipated discharge and homelessness with no resources, medical care, or information on how to file an appeal. On 10/23/25 at 1:52 p.m. an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (Admin). The IJ began on 9/24/25 when the facility failed to reassess or allow readmission to Resident 1 which resulted in Resident 1's homelessness. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident out of three sampled residents (Resident 1) was provided with the required discharge notices, when Resident 1 was discharged from the facility. This failure resulted in Resident 1's denied access for advocacy and information for appeal options before being discharged unexpectedly to her car.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accurate accountability of controlled medication when: 1. There was a discrepancy between the Controlled Drug Record (CDR-inventory sheet that keeps record of the usage of controlled medications) and medication blister card (medcard-a type of medication packaging) for Resident 76, Resident 151 and Resident 17. 2. A bottle of morphine sulfate solution (controlled medication [medication with high potential for abuse or addiction] to relieve pain) was not reconciled properly. These failures resulted in the facility not having an accurate accountability of controlled medications, and the potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication error rate was not less than 5% when the error rate was 17.86% based on five medication errors out of 28 opportunities observed during a medication pass observation for three out of six residents (Resident 7, Resident 204 and Resident 351). This failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and had the potential to affect the resident's clinical conditions.

Inspectors wroteBased on observation, interview and facility policy and procedure (P&P) review, the facility failed to ensure the residents' medications were stored and labeled properly when: 1. An insulin pen did not have an open date on it. 2. Methadone (controlled medication to relieve pain) pills were not stored in their original packaging. 3. A bottle of morphine sulfate solution was not in the correct box and did not have the correct administration instruction on the label. These failures had the potential for medication diversion, medication errors and resident exposure to the expired medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety for a census of 103 residents out of a census of 104 who ate facility prepared food when: 1. Thick, black, charcoal-like debris was found between all spokes of the two front gas burners of the facility stove, 2. [NAME] 2 handled parsley with her bare hands then placed it directly on the resident plate, and when 3. [NAME] 2 scratched her back and continued plating food without washing her hands. These failures increased the risk for the spread of infection and reduced the facility's potential to prepare residents' food in a sanitary manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed of properly when a large amount of cardboard and miscellaneous items was strewn around and under the garbage dumpsters at the back of the facility. This failure increased the risk of attracting of pests and spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for a census of 104 when: 1. TB (tuberculosis, a contagious lung infection) screening and testing was not done for three sampled residents (Resident 3, Resident 8 and Resident 79), 2. No Enhanced Barrier Precautions (EBP, wearing a gown and gloves during high-contact care activities with patients who are at risk of spreading multidrug-resistant organisms (MDROs), like those with open wounds or indwelling medical devices, to prevent the spread of these infections, even when full contact precautions aren't needed) were used for three sampled residents (Resident 9 and Resident 151 ) who had wounds, 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident needs were accommodated for two of 23 sampled Residents (Residents 6 and 307), when the call light was not within reach. This failure had the potential to result in the residents not attaining their highest practicable physical, psychosocial and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to timely submit a Minimum Data Set (MDS- a federally mandated resident an assessment tool) for one of 23 sampled residents (Resident 85) when a discharge MDS from 10/24 had not yet been submitted. This failure resulted in inaccurate data being transmitted and resulted in Resident 85's discharged MDS data not received by the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a comprehensive and person-centered care plan was implemented for one of 23 sampled residents (Resident 26). This failure posed the risk of not providing appropriate, consistent and individualized care plan for Resident 26 to attain their highest practicable physical, mental and psychosocial wellbeing. A review of Resident 26's admission record indicated he was admitted 7/22 with diagnoses including dementia (a progressive state of decline in mental abilities.) A review of Resident 26's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 6/26/24 indicated Resident 26 was totally dependent for all his care, with dependent assistance for bed mobility, dressing, hygiene, activities including for sit to stand. The MDS indicated bed to chair transfer was not attempted by staff. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to meet the professional standards of nursing practice for one of 23 sampled residents (Resident 7), when there was no order for a Foley catheter. This failure placed the resident with a Foley catheter at risk for not getting proper nursing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food preferences were honored for one (Resident 1) of 11 sampled residents when Resident 1's dislike food item was served. This failure had the potential to negatively impact Resident 1's nutritional status.

Inspectors wroteBased on interview and record review the facility failed to provide services according to professional standards of quality for one of 3 sampled residents (Resident 1) when Resident 1's pain medication was not administered per physician order. This failure decreased the facility's potential to safely follow the physician's order which led to unmet pain needs.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #72) of 2 residents reviewed for vision services received treatment to maintain vision abilities. Specifically, the facility failed to obtain an ophthalmology appointment for the treatment of cataracts for Resident #72, who requested multiple times to be seen by a specialist for treatment. This failure resulted in Resident #72's vision worsening.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to ensure that activities were provided to meet the resident's preferences, and the resident was included in group activities for 1 (Resident #99) of 2 sampled residents reviewed for activities.

Inspectors wroteBased on observations, record reviews, interviews, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent (%). The facility medication error rate was 7.14%, resulting from two medication errors in 28 opportunities. This affected 2 (Resident #15 and Resident #271) of 5 residents observed during the medication pass observation.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to ensure a clean barrier on which to set supplies was used during wound care and failed to ensure full glove changes were completed, and hand hygiene was completed between glove changes during the provision of wound care. This affected 1 (Resident #63) of 1 resident observed receiving wound care.

Inspectors wroteBased on interview and record review the facility failed to provide treatment and care in accordance with professional standards of care for one of four residents (Resident 1) when: 1. The facility failed to accurately enter the physician's order for alendronate (a medication to make bones stronger) into Resident 1's medical record; and 2. Resident 1 received an incorrect dose of alendronate. These failures had the potential for Resident 1 to experience adverse side effects and not attain her highest practicable physical, psychosocial, and mental well-being.