Oakcrest Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 8 (Resident #2) residents reviewed for resident rights.1. The facility failed to ensure that Resident #2's room was free from standing urine and bugs on 3/11/2026.2. The facility failed to ensure that Resident #2's curtain was clean and free of stains on 3/11/2026.3. The facility failed to ensure the flooring was not damaged in the east hallway on 3/11/2026. These failures placed residents at risk for an unclean, unsafe, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 1 of 8 (Resident #1) residents reviewed for comprehensive care plans. The facility failed to include Resident #1's history of trauma, history of delusions, and diagnoses of schizophrenia and bipolar disorder were captured in her comprehensive care plan. This failure placed residents at risk of not receiving interventions to address their diagnoses and trauma.

Inspectors wroteBased on interview, observation and record review the facility failed to maintain infection control practices during food preparation for 1 of 1 meal observed for meal preparation. The DS failed to maintain infection control practice by:1. The DS failed to complete hand hygiene appropriately.2. The DS failed to sanitize the thermometer with a clean alcohol swab between food items. 3. The DS failed to sanitize the thermometer after touching another surface with the thermometer. These failures could result in cross contamination or food allergies. Findings Include: An observation was conducted on 08/06/2025 at 11:25AM while the DS pureed the food for lunch. The DS had placed the chicken into the puree blender and completed the puree process. After the DS emptied the chicken out of the blender, the DS moved onto the next food item to puree. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a person-centered care plan for 3 of 3 (Resident #52, Resident #7 and Resident #35) residents reviewed for care plans. The facility failed to ensure Resident #52, Resident #7 and Resident #35 had a person-centered care plan developed and implemented to meet the resident's medical, physical, mental and psychosocial needs, including the diagnosis of Dementia/Alzheimer's. This failure could result in residents not getting the specialized care that they need for their diagnosis. Findings Include: RR of Resident #52's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 7 residents (Resident #50, Resident #24, Resident #20, Resident #35 and Resident #11) reviewed for pharmaceutical services. The facility failed to document the administration of controlled medications from the medication cart on the narcotic count sheets for Resident #50, Resident #24, Resident #20, Resident #35 and Resident #11. This failure could place residents at risk of not receiving a therapeutic dosage of medication, drug diversion, and overdose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates for 1 (MR E) of 2 medication rooms and 1 (MC A) of 3 med carts reviewed for pharmaceutical services.1. A supplement drink named Med Pass 2.0 + was left opened and dated, and not on ice inside of MC A.2. Over the counter medications (OTC) that had been opened, had no date indicating when they were opened in MR E This failure could lead to medication not being effective, and therefore impacting resident health. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 5 of 7 residents (Resident #2, Resident #3, Resident #46, Resident #22, and Resident #52) reviewed for infection control. 1. The facility failed to ensure LVN E cleansed her hands by handwashing/hand hygiene with alcohol-based rub before and after blood sugar checks for Resident #2 and Resident #462. The facility failed to ensure CNA B was cleansing male residents properly and conducting hand hygiene and glove change during peri-care for Resident #22 and Resident #52.3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the facility maintained a home-like environment for 2 of 2 (Resident # 2, Resident # 63) Residents reviewed for home-like environment. The facility failed to ensure that Resident #2's and Resident #63's bedroom was home-like and free from worn and destroyed walls. This failure could result in psychological distress and feeling uncomfortable in the facility. Findings Included: RR of Resident #2 's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a diagnosis of Type II Diabetes Mellites (chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels), Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves), and Muscle Weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rates are not 5 percent or greater for 1 of 8 residents (Resident #3) reviewed for medication administration. 1. LVN E did not check with order for the parameters on the chart; only on the medication label itself before administering insulin to Resident #3.2. The CMA did not administer two medications (Ferrous Sulfate 325mg 1 tablet every day and Cholecalciferol 25mcg 1 tablet one time a day) to Resident #3. This failure could potentially exacerbate the residents' diagnosis and lead to hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a call light was accessible while in bed for 1 of 1 (Resident #2) Residents reviewed for call lights. The facility failed to ensure that Resident #2 had a call light next to their bed. This failure could result in a resident not being able to call for help during an emergency. Findings Included: RR of Resident #2 's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a diagnosis of Type II Diabetes Mellites, Schizophrenia, and Muscle Weakness. RR of Resident #2's MDS record dated 05/25/2025 revealed the resident had a BIMS score of 15 which indicate no cognitive impairment. An observation was conducted on 08/05/2025 at 12:30PM in Resident #2's bedroom where a call light was missing from the call light spot located between the two resident's beds. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #43, Resident #47 , Resident #52, Resident #57, and Resident #67) reviewed for comprehensive care plans. These failures could place residents at risk of not having individual needs met, a decreased quality of life, causes residents not to receive needed services and death. 1. The facility failed to ensure Resident #47's care plan was comprehensive and updated to reflect he needed assistance with feeding and was a choking risk. An IT was identified on 07/16/2024 at 12:00 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #47) of 5 residents reviewed for accidents. The failed to ensure resident #47 was being monitored during meal intake resulting Resident #47 choking and ultimately passing away. This failure could result in other residents not getting the assistance or the supervision needed when they have swallowing difficulties and could also lead to severe injury and/or death. An IT was identified on 07/16/2024 at 12:00 PM. The IT template was provided to the facility on [DATE] at 12:47 PM. The IT was removed on 07/17/2024, the facility remained in violation at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate because the facility failed to

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately or within 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials for 1 of 5 residents (Resident #47) reviewed for abuse and neglect in that: The facility failed to report to the State agency when Resident #47 had an incident of choking on 05/16/2024. He was pronounced dead at the facility by EMS on 05/16/2024 at 6:04 PM. This failure could place current residents on a mechanically altered diet at risk of having an incident go unreported and uninvestigated.

Inspectors wroteBased on observation, interviews, and record review the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals for 1 of 1 resident (Resident #1) reviewed for pharmacy services and procedures in that: The facility failed to ensure medication administered to a resident #1 was properly administered and not left in the room. This failure could place residents at risk of not receiving their physician ordered medications resulting in a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accident hazards/supervision. Resident #1 walked out of the facility unattended on 04/01/24 at 8:08PM and remained missing as on 04/10/24 at 3:00PM. LVN B failed to physically check during the two-hour monitoring to ensure Resident #1 was in the building during and after his elopement. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. While the IJ was removed on 04/05/24 at 9:12AM, the facility remained out of compliance at a scope of isolated and a severity level of no actual ham but potential for harm as the resident was missing as on 04/10/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for six of 24 (Residents #6, #13, #15, #39, #44 and #52 ) residents reviewed for activities. 1. The facility failed to develop an activity program based on the preferences and suggestions of the resident population. 2. The facility failed to provide activities as scheduled on their activity calendar. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for one of two wings (West) reviewed and three of five posted evacuation routes reviewed. 1. The facility failed to updated floor plans with evacuation route when they closed two of the facility's seven fire exits due to construction. 2. The facility failed to ensure that boards nailed over a non-functioning exit door were free of broken, splintered ends accessible to residents on the [NAME] wing. These failures placed residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for one of two wings (West) reviewed and three of five posted evacuation routes reviewed. 1. The facility failed to updated floor plans with evacuation route when they closed two of the facility's seven fire exits due to construction. 2. The facility failed to ensure that boards nailed over a non-functioning exit door were free of broken, splintered ends accessible to residents on the [NAME] wing. These failures placed residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for one (Resident #32) of 24 residents reviewed for dignity, in that: LVN A was standing over Resident #32 while assisting him for breakfast. This deficient practice could affect residents by placing them at risk for diminished quality of life, loss of dignity and decline in self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 24 (Residents #6, #13, #15, #39, #44, and #52) reviewed for care plans. The facility failed to provide care planning for activities for Residents #6, #13, #15, #39, #44, and #52. This failure placed residents at risk of not having their recreational needs met.

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 one of one (Resident #17) resident and 1 of 1 nurse (LVN A) observed for G-Tube medication administration. LVN A failed to maintain the G-tube tubing tip and syringe plunger clean while administering G-Tube medication. This failure could place residents with G-tubes at risk of decline in health due to inappropriate G-tube care and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post nurse staffing data on a daily basis at the beginning of each shift in a clear and readable format and in a prominent place readily accessible to residents and visitors for two of three days of the recertification survey. The facility failed to post nurse staffing information on 05/02/23 and 05/01/23. This failure placed residents and visitors at risk of being unaware of the facility daily staffing requirements.