Oak Haven Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview and record review, The facility failed to ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision; and failed to ensure the resident's (#61) environment remained as free of accident hazards as possible for 1 (#61) of 5 sampled residents reviewed for elopement risk. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#61) of 5 sampled residents reviewed for elopement. The facility failed to ensure staff were knowledgeable and able to identify residents at risk for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #61) of 5 sampled residents reviewed for elopement. The facility failed to:1. Ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision;2. Ensure staff were knowledgeable and able to identify residents at risk for elopement;3. Implement appropriate interventions and/or increase supervision after identifying the wanderguard security system was not functioning properly; and4. Ensure the resident's environment remained as free of accident hazards as possible. [...]

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information on a daily basis that included in part the total number and actual hours worked by RNs, LPNs and CNA staff directly responsible for resident care per shift. The facility census was 93.

Inspectors wroteBased on observations and interviews, the facility failed to ensure pureed foods were prepared using methods that preserved its nutritional value. The facility failed to follow a recipe regarding portion size and ingredients while preparing pureed food, thereby compromising the nutritional adequacy of the meal for all 12 residents on a puree diet. Total facility census was 93.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Total facility census was 93.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that dietary support personnel were competent to safely and effectively perform the functions of the food and nutrition service. This deficient practice had the potential to affect the 89 residents who were prepared and served meals from the kitchen. During the initial tour of the kitchen on 12/01/2025 at 09:00 a.m., revealed no documentation reflecting dishwasher temperatures and sanitation checks were being performed routinely in the kitchen. In an interview on 12/01/2025 at 10:45 a.m., S6Dietary revealed he had been employed at the facility for about 3 months and is a dietary aide in the kitchen. S6Dietary revealed he was not trained on how to properly wash and sanitize dishes. S6Dietary revealed he did not know how to set up a 3-compartment sink. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that pureed food was prepared using methods that preserved its nutritional value. The facility failed to follow a recipe regarding portion size and ingredients while preparing pureed food, thereby compromising the nutritional adequacy of the meal for all 7 residents on a puree diet. Review of facility policy titled Puree Food Preparation revised 09/01/2024, revealed in part. It is the policy of this facility to provide puree food that has been prepared in a manner to conserve nutritive value, palatable flavor, and attractive appearance. 6. Resident receiving puree diets should always receive portions equivalent to those served on the regular or therapeutic diet ordered per policy and procedure. 7. Puree Food Preparation Guidelines per serving: Vegetables (leaf, stem, or flower): Add 2 tablespoons mashed potato flakes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and failed to store food in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 89 residents who received meals from the kitchen. The facility failed to ensure:1. Dish washing machine temperature and sanitizer status are monitored and logged daily.2. Coolers and freezer temperatures are monitored and logged daily.3. Food temperatures are recorded daily to ensure food is at the proper temperature before trays are assembled.4. Dietary staff wore hair restraints while preparing food. Review of facility policy titled Dietary Personal Hygiene, revised 09/1/2024, revealed in part. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided by the facility to meet quality professional standards for 1 (Resident #4) of 4 (#1, #2, #3, #4) sampled residents. The facility failed to ensure Resident #4's physician's orders for a dietary supplement was carried out. Review of facility policy titled, Nutritional and Dietary Supplements, revised 09/01/2024, revealed in part. It is the policy of this facility that nutritional and dietary supplements will be used to complement a resident's dietary needs in order to maintain adequate nutritional status and the resident's highest practicable level of well-being. The facility will provide nutritional and dietary supplements to each resident, consistent with the residents' assessed needs. [...]

Inspectors wroteBased on record review and interviews, the facility failed to act promptly upon the grievances voiced by residents during monthly Resident Council meetings.

Inspectors wroteBased on observation and interview, the facility failed to ensure controlled medications were stored in separately locked compartments in 1 (Medication Room A) of 2 (Medication Room A and Medication Room B) medication rooms observed.

Inspectors wroteBased on record review and interview the facility failed to ensure the Resident's right to formulate an advanced directive was properly reflected in the Resident's medical record for 1 (#4) of 1 Residents reviewed for advance directives. The facility failed to ensure all medical records regarding advance directives consistently reflected Resident #4's wishes to be a DNI (Do not intubate). The total sample size was 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #68) of 29 sampled residents.

Inspectors wroteResident #76 Review of Resident #76's electronic medical record revealed an admission date of 02/29/2024, with diagnoses that included, in part . Alzheimer's, Dementia with Behavioral Disturbance, Anxiety Disorder, and Major Depressive Disorder with Severe Psychotic Symptoms. Review of Resident #76's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/2025 revealed, in part .a Brief Interview for Mental Status (BIMS) score was not provided due to the resident being rarely or never understood. Resident #76 had 2 or more falls without injury and 1 fall with minor injury. Review of Resident #76's current care plan revealed, in part .I am at risk for falls related to confusion and being unaware of safety needs, initiated on 03/13/2024. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide care and services that met professional standards of quality for 1 (#41) of 2 (#41 and #60) residents observed during medication pass. The facility nurse failed to properly position Resident #41 for administration of a breathing treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the necessary care and services to ensure a resident maintained the ability to carry out activities of daily living. The facility failed to provide a communication aid for 1 (Resident #26) of 2 (Resident #26 and Resident #68) residents sampled for communication and sensory concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and assistive devices to maintain and/or improve hearing ability for 1 (Resident #68) of 2 (Resident #26 and Resident #68) residents reviewed for communication and sensory.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion by failing to provide restorative therapy for 1 (#80) of 3 (#16, #54, and #80) residents reviewed for limited range of motion.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 94.

Inspectors wroteBased on observation and interview the facility failed to ensure garbage and refuse were disposed of properly. This deficient practice had the potential to affect all 94 residents who resided in the facility.

Inspectors wroteBased on interview and record review the facility failed to include the Administrator or designee in the Quality Assessment and Assurance Process Quarterly meeting. Total sample size 29.

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 of communicable diseases and infection by: 1. failing to ensure staff wore masks as directed; 2. failing to ensure staff followed proper infection control practices during wound care for Resident #28; and 3. failing to ensure S19 Infection Preventionist performed accurate infection surveillance and reporting.

Inspectors wroteBased on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to provide an uncluttered neat and well-kept room for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on interview and record review the facility failed to develop/implement a Person-Centered Care Plan for 1 (Resident #1) out of 3 (Resident #1, Resident #2 and Resident #3), sampled residents to include smoking and appropriate nursing interventions.

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 of communicable diseases and infection by failing to ensure staff performed hand hygiene after touching contaminated areas during wound care for 1 (Resident #3) out of 3 (Resident #1, Resident #2 and Resident #3), sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision, and use extensive, 2 person physical assistance for turning, repositioning and bed mobility for 1 (#1) of 2 (#1 and #2) residents reviewed for falls. This failed practice resulted in an actual harm situation on 11/07/2024 at 9:35 a.m., when Resident #1, who was severely impaired cognitively; had diagnoses that included Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side; Unspecified Dementia; and required substantial/ maximal assistance for shower/ bathing and rolling left and right; rolled out of bed while receiving a bed bath by S4 CNA. Resident #1 fell onto the floor, and sustained a Closed Right Hip Fracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive plan of care was reviewed and revised to ensure staff provided extensive assistance with 2 person physical assistance for turning, repositioning and bed mobility, when providing ADL care (bed bath), for 1 (#1) of 2 (#1 and #2) residents reviewed for falls.

Inspectors wroteBased on interview and record review facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders, and the resident's advance directives for 1 (Resident #76) of 2 (Resident #76 and Resident #77) closed records reviewed out of a total sample of 23. The facility failed to: 1. Ensure S4 LPN acted in accordance with Resident #76's Advanced Directives and Physician Orders, and initiated CPR when the resident was found unresponsive and without a pulse; and 2. Ensure EMS and the physician were notified when Resident #76 was found unresponsive, without a pulse. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 5 (#7, #8, #16, #279 and #280) of 5 Residents who were ordered and served pureed diets.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure cognitively impaired residents were treated with respect and dignity, and cared for in a manner that promoted enhancement of his or her own quality of life for 1 (#68) of 1 Resident reviewed for dignity in a total sample of 23. The facility failed to ensure Resident #68, who received PEG tube feedings and was NPO, was not placed within sight of the dining area during meal service.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician concerning a significant change in a resident's physical, mental or psychosocial status for 1 (Resident #76) of 23 sampled residents.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide care and services that meet professional standards of quality, by failing to replace the tube feeding syringe and label the flush set bag for 1 (#68) of 3 (#68, R1, R2) Residents who received Enteral Tube Feedings.

Inspectors wroteBased on observation, interview and record review the Facility failed to provide respiratory care consistent with professional standards for 1(Resident #31) of 2 Residents (Resident #27 and Resident #31) reviewed for respiratory care. The Facility failed to ensure respiratory equipment was properly changed, labeled and stored. Total sample was 23.

Inspectors wroteBased on interview and record review, the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, and submit a report of findings for 1 (#2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents.

Inspectors wroteBased on record review and interview the facility failed to develop an individualized person-centered plan of care to meet the needs of 1 (#2) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. The facility failed to ensure a plan of care was developed with approaches for aggressive behavior.