Great Oaks Rehabilitation and Healthcare Center

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed and transmitted within CMS (Centers for Medicare and Medicaid Services) required time frames for one (1) of 14 MDS assessments reviewed. Resident #30. Findings Include:Record review of CMS Version 3.0 Manual revealed under Chapter 5, Submission and Correction of the MDS Assessments.5.2 Timeliness Criteria. For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD). For Entry and Death in Facility tracking records, the MDS Completion Date must be no later than 7 days from the Event Date. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to notify the provider to clarify missing orders for previously established interventions following a resident's return from the hospital. This resulted in a lapse in continuity of care for one (1) of three (3) residents reviewed for hospital readmission. Resident # 1. Findings Include: Record review of July 2025 Order Summary Report for Resident #1 revealed an abduction pillow, and nutritional supplement was ordered prior to hospital transfer on 8/15/25. Review of the After Visit Summary dated 8/18/2025 showed no mention of these interventions. Upon readmission, the facility did not contact the provider to clarify whether the interventions should be resumed, and the interventions were not reinstated. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to report an injury of unknown origin to the State Agency (SA) as required for one (1) of three (3) residents reviewed for injuries. Resident #1. Findings Include:Record review of the facility's policy titled Abuse Prohibition Policy revealed: The Abuse Coordinator will report such allegations to the state agency in accordance with the state law .The Abuse Coordinator will report .injuries of unknown source with serious bodily injury within two (2) hours of the allegation. Review of the facility's investigation, provided by the Administrator (ADM), revealed that on 5/28/25, Resident #1 experienced a syncopal episode and was transferred to the emergency room (ER). [...]

Inspectors wroteBased on staff interview record review, and facility policy review the facility failed to conduct a prompt and thorough investigation of an injury of unknown origin to determine whether abuse, neglect, or a clinical cause contributed to the injury for one (1) of three (3) residents reviewed for injuries. Resident #1. Findings Included: Record review of the facility's policy titled Abuse Prohibition Policy revealed: Investigation: 1. The facility will thoroughly investigate all alleged violations and take appropriate actions. 5. Investigations will be prompt, comprehensive, and responsive to the situation and contain founded conclusions. Review of the facility's investigation, provided by the Administrator (ADM), revealed that on 5/28/25, Resident #1 experienced a syncopal episode and was transferred to the emergency room (ER). [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical record was maintained when a verified exercise order was not entered into the electronic medical record, resulting in an incomplete clinical record for one (1) of three (3) sampled residents reviewed for medical record accuracy .Resident #1. Findings Included: Record review of a Return to Work/School form provided by the Orthopedic Physician's office for Resident #1 revealed and order, dated 7/18/25, for work on passive exercises for lower extremity due to patient non weight bearing status for 1-2 times a week. Work on active range of motion for upper extremity to ensure tone and minimalize stiffness for 1-2 times a week. The form was initialized and dated 7/22/25. Review of Resident #1's physician orders for July 2025 revealed no documentation that the new exercises were ordered. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to notify a resident and/or a legal representative of the risks and benefits of using a psychotropic medication for four (4) of 42 residents reviewed for psychotropic drug use. Resident #8, #13, #21, and #23 Findings Include: Review of the facility policy titled Psychotropic/Psychoactive Medication Policy with a revision date of 6/24/25 revealed under, Policy Implementation: . 5. All residents have full rights to participate or refuse treatment. Before initiating or increasing psychotropic medication the resident and or responsible party must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication. The risk and benefits should be clearly explained . [...]

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to ensure a residents call light was accessible for one (1) of 50 residents in the facility. Resident #155 Findings Include: Review of the facility policy titled Resident Call System with a revision date of 3/28/23 revealed under, Policy Interpretation and Implementation: 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . An observation of Resident #155 on 6/23/25 at 9:26 AM revealed she was lying in bed with the call light on the floor under the bed. During an interview, Resident #155 voiced this happens often. She stated, The staff walk out and don't give me my call light, and I don't have any way to call them. [...]

Inspectors wroteBased on observation, staff interview, and record review the facility failed to provide a resident with a wheelchair in good repair for one (1) of 50 residents requiring a wheelchair in the facility. Resident #49 Findings Include: The facility provided a statement on letterhead that read, (Proper name of facility) does not have a policy specifically regarding wheelchair good repair/condition. During an observation of Resident #49 on 6/23/25 at 10:38 AM, he was propelling himself in his wheelchair down the hallway and into his room. Both arm rest were in disrepair, torn and tattered with the white foam visible and a silver screw head exposed on both sides. An observation and interview with Registered Nurse (RN) #1 on 6/24/25 at 7:55 AM confirmed Resident #49's wheelchair arm rest were in poor condition and stated he could get injured or scraped. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for one (1) of 16 residents' MDS reviewed (Resident #52).

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure a safe environment by not preventing hazardous substances from being stored in a resident's room, thereby creating the potential for accidental ingestion and harm. Specifically, the facility failed to prevent a resident's family from placing two homemade containers of ant bait (containing boric acid) in the resident ' s room, which remained accessible to Resident #15 and potentially to other cognitively impaired, wandering residents. This deficient practice affected one (1) of fifty (50) residents reviewed (Resident #15). Findings Include: Review of the typed statement on facility letterhead revealed the facility did not have a policy regarding storing hazardous materials in residents rooms and was signed by the Administrator. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure that an indwelling urinary catheter was clinically indicated and ordered by the provider for one (1) of three (3) residents reviewed with catheters (Resident #105).

Inspectors wroteBased on observations, resident, staff, and family interviews, record review, and facility policy review, the facility failed to maintain a safe environment and provide adequate supervision and equipment to prevent accidents for one (1) of four (4) sampled residents. Resident #1. Specifically, staff removed the resident's bed rails without a safety assessment and as a result, the resident rolled out of bed, during care and sustained a head laceration, suffered pain and required emergency room treatment, including x-rays and stitches. Findings Include: Review of the facility policy titled Fall Prevention Program with a review date of 6/10/24 revealed under, Policy: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change thereafter. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review the facility failed to provide sufficient staffing to ensure residents needs were met in a timely manner for five (5) of seven (7) residents reviewed. Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. Findings Include: Record review of the facility policy, Staffing, Sufficient and Competent Nursing with reviewed date of 03/2023 revealed, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day, seven (7) days a week to provide competent resident care services including: a. assuring resident safety, b. [...]

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to protect a resident's right to be free from misappropriation of property for one (1) of five (5) sampled residents. Resident #1.

Inspectors wroteBased on staff and resident Resident Representative (RR) interview, record review and facility policy review the facility failed to notify the RR of a change in a medication for one (1) of three (3) residents reviewed. Resident #1. Findings Included: Review of the facility policy titled, Change of Condition and Physician/Family Notification with a review date of January 2023 revealed Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: .A need to significantly alter treatment Procedure . the licensed nurse will contact the resident's family and their physician. On 05/15/24 at 9:20 AM, an interview with Resident #1's RR revealed that Resident #1 was admitted to the facility on [DATE] for skilled therapy services. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to prevent the potential spread of infection when staff failed to sanitize hands between a respiratory treatment and peg (percutaneous endoscopic gastrostomy) tube medication administration and failed to clean and properly store a respiratory mask and peg tube syringe for (1) one of (8) resident care observations.

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to ensure the resident's right to formulate an Advance Directive (Resident #15 & 50) or identify if a resident had an Advance Directive (Resident #34) for three (3) of 18 residents reviewed for Advance Directives. Findings Include: Review of the facility policy titled, Advance Directives with a revision date of 8/2023 revealed, Policy Interpretation and Implementation .1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an advance directive if he or she chooses to do so . Record review of Resident #34's Advance Directive Policy that was electronically signed by the resident's representative revealed there was no indication if the resident had an Advance Directive. [...]

Inspectors wroteBased on staff interview, record review and Resident Assessment Instrument (RAI) Manual review, the facility failed to submit Minimum Data Set (MDS) assessments within 14 days of the MDS Completion Date for three (3) of 18 MDS resident assessments reviewed, Resident #12, Resident #14, and Resident #32. Findings Include: An interview on 1/4/24 at 11:00 AM, with the Director of Nurses (DON) revealed the facility uses the RAI Manual as the MDS Policy for the facility. Review of the RAI Manual dated October 2023 revealed under 5.2 Timeliness Criteria .facilities participating in the Medicare and Medicaid programs must meet the following conditions: .Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument .Assessment Transmission: [...]

Inspectors wroteBased on observations, staff interview, record review and facility policy review the facility failed to implement a care plan for Activities of Daily Living (ADL) for one (1) of 18 residents care plans reviewed. Resident #6.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to administer a medication as the physician ordered for (1) one of 28 medication administration opportunities.

Inspectors wroteBased on observation, staff and family interview and facility policy review the facility failed to provide timely incontinent care for a resident who had a bowel movement as evidenced by the resident waiting an hour and a half for incontinent care for one (1) of 18 Residents sampled.

Inspectors wroteBased on observation, staff interview, record review, and policy review the facility failed to ensure medications were secured when a medication cart was left unlocked and unattended with medications left on top of the cart for (1) one of (5) five medication administration observations.