Hebron Oaks

Inspectors wroteBased on interview, record review and policy review, the facility failed to protect the resident's right to be free from verbal and physical abuse by a Registered Nurse (RN A). This failure affected 1 of 3 residents (R1) reviewed for abuse. Resident #1 was subjected to verbal and physical abuse on 10/09/2025, when Registered Nurse (RN) A verbally berated the resident and turned the resident onto their side against their will. This failure resulted in unnecessary pain and anxiety for the resident.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to report an allegation of abuse within the required timeframe for 1 (Resident #1) of 3 residents reviewed for abuse prohibition.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to protect residents from potential further abuse by allowing an alleged abuser to return to the facility during an ongoing investigation of staff-to-resident abuse involving 1 (Resident #1) of 3 residents reviewed for abuse prohibition. On 10/09/2025 around 5:00 PM, Resident #1 was subjected to verbal and physical abuse from Registered Nurse (RN) A. RN A re-entered the facility on 10/11/2025, 10/12/2025, and 10/13/2025 during an ongoing investigation. This failure resulted in RN A having access to all residents of the facility during an ongoing investigation of an allegation of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food was stored, prepared, and served in a safe and sanitary manner. This practice has the potential to affect all 42 residents who reside at the facility. Surveyor observed left over food items not properly covered, labeled, and expired. Surveyor observed walk in freezer to have a large puddle of water outside freezer, door sticking, and to the front left side of the freezer large chunks of ice covering boxes of food and left over food item. Surveyor observed cleanliness concerns in main kitchen. Surveyor observed staff in kitchen and kitchenette not wearing beard restraints. Surveyor observed staff wearing gloves, touching cabinets and door handles, and then directly touching food with same pair of gloves. During dishwashing Surveyor observed staff going from dirty to clean with no handwashing in between. [...]

Inspectors wroteBased on interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. RN J's (Registered Nurse) background check information did not include an out of state criminal background check.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to promote healing, prevent infection, and prevent new injuries from developing for 2 of 3 residents (R1 & R3) reviewed with pressure injuries or at risk for developing pressure injuries. R1 was admitted on [DATE], without a pressure injury. R1 developed three pressure injuries - two identified as Deep Tissue Injuries (DTIs; a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscle, fat, and tendons) and one Unstageable (a full thickness wound where the base of the injury is obscured by a layer of dead tissue called slough or eschar). [...]

Inspectors wroteBased on record review and staff interviews, the facility did not complete a performance review of every nurse aide at least every 12 months for 5 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training. The survey team randomly selected five (5) facility CNAs who have been employed at the facility for longer than one (1) year. CNA/MT O (Certified Nursing Assistant/Medication Technician), CNA/MT P (Certified Nursing Assistant/Medication Technician), CNA Q (Certified Nursing Assistant), CNA R (Certified Nursing Assistant), and CNA S (Certified Nursing Assistant) did not have a performance review at least every 12 months.

Inspectors wroteBased on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 32 residents. Hood vents with visible clumps of dust. Kitchen staff with facial hair were not wearing beard restraints.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents with a pressure ulcer or at risk for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure ulcers and to promote healing for 3 (R21, R16, and R25) of 5 residents reviewed for pressure ulcers and 1 (R6) of 1 supplement. R21's heels resting directly on Broda chair and sling left behind R21 while sitting in Broda chair. -R16's heels directly on mattress while lying in bed. -R6's heels resting directly on Broda chair and sling left behind R6 while sitting in Broda chair. -Surveyor observed wound care for R25 performed where hand hygiene and aseptic technique were not completed per current professional standards of practice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that parenteral medications were administered consistent with professional standards of nursing practice for 1 of 1 (R133) of 12 residents reviewed. R133 was admitted to the facility on [DATE], with a Peripherally Inserted Central Catheter (PICC) line, which is a soft, thin, flexible tube in a vein used to administer IV medications and fluids. Staff did not complete appropriate hand hygiene and glove changes during administration of IV antibiotics. The facility policy, titled, Gloves - Use Guidelines, dated, 1/28/22, indicates, in part: It is the practice of this facility that gloves be worn .when performing vascular access procedures including starting intravenous lines, drawing blood, and doing finger sticks. Guidelines: I. Selection of Gloves. A .4. [...]