Seven Oaks Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not keep the following equipment and surfaces clean and free of debris in the kitchen in that: 1. The stove back splash wall was not clean2. Burners on the stove were caked with food items3. Ovens were dirty4. Deep fryer had crumbs and dried food items5. Fans in the walk-in cooler had dust / debris6. Air vents with visible build-up7. Wash rags stored beneath hand-washing sinkThe facility did not properly store prepared food items in the walk-in cooler in that:1. Two prepared bowls of pears on a tray in the walk-in cooler were left uncoveredThe facility did not properly store frozen food items in the stand-alone freezer in that:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen in that: Two of four stove burners were non-functioning. This failure could place residents at risk of consuming contaminated food from a poor sanitation environmentThe

Inspectors wroteBased on observations, interviews, and record review the facility failed ensure each resident receives and the facility provides food that accommodates residents' food preferences for 3 of 22 residents (Resident #29, Resident #15, and Resident #3) reviewed for food preferences and the accommodation of resident's meal choices.1. The facility did not honor Resident #29's preference for milk with her supper meals. 2. The facility failed to honor Resident #15's preferences for a bacon and toast for breakfast.3. The facility failed to provide condiments (jelly and butter) and bread for Resident #3 on 07/20/25. These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to and the facility made prompts efforts to resolve grievances the resident may have for 1 of 2 residents (Resident #3) reviewed for grievances. The facility failed to ensure a grievance was filed and Resident #3 was appropriately apprised of progress toward resolution when Resident #3's green pants were not returned from the laundry. This failure could place residents at risk for grievances not being addressed or resolvedFindings include:Record review of Resident #3's face sheet, dated 07/23/25, reflected Resident #3 was a [AGE] year-old female readmitted to the facility on [DATE] with a diagnosis which included Alzheimer's (progressive disease that destroys memory and other important mental functions). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 4 residents (Resident #8 and Resident #9) reviewed for PASRR. 1. The facility failed to complete the PASRR level 1 screening for Resident #8 who had a diagnosis of Bipolar with depression and psychotic disorder (where the individual is experiencing a depressive episode that is both severe and includes psychotic symptoms) on admission on [DATE]. 2. The facility failed to ensure Resident #9 had a new PASRR level 1 screening completed when she had a new diagnosis of schizoaffective disorder (a chronic brain disorder that significantly impacts a person's thoughts, feelings, and behavior) dated 04/05/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 breakfast meals reviewed for dietary services. The facility failed to serve an appetizing bowl of oatmeal. The oatmeal served was thick, porous texture that resembled cornbread during the breakfast meal on 07/22/25. This failure could place residents at risk of weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received food prepared in a form to meet their individual needs for 4 of 4 residents (Residents #13, #27, #28, and #12) reviewed for the lunch menu on 07/21/25. The facility failed to ensure Residents #13, #27, #28, and #12 was served the correct portion of food on 07/23/25. These failures could place residents at risk of inadequate nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 2 of 15 residents (Residents #12 and #28) reviewed for therapeutic diets. 1. The facility did not ensure Resident #12 was given double protein portion as ordered by the physician. 2. The facility did not ensure Resident #28 was given large protein portions as ordered by the physician on 07/21/25 during the lunch service. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: 1. Record review of Resident #12’s face sheet, dated 07/23/25, reflected Resident #12 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included absence of right leg below knee. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 ice machine reviewed for kitchen sanitation. The facility failed to ensure the ice machine, stored in the kitchen area, was free from a pink like substances on it and black like substance in the scoop container on 07/21/25. This failure could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 2 of 2 residents (Residents #12 and #21) reviewed for accidents and hazards.1. The facility failed to ensure Resident #12 did not have an electric razor and shaving gel on his bedside table on 07/21/25, 07/22/25 and 07/23/25.2. The facility failed to ensure Resident #21 did not have razors in his bathroom on 07/21/25, 07/22/25 and 07/23/25. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in healthFindings include: 1. Record review of Resident #12’s face sheet, dated 07/23/25, reflected Resident #12 was a [AGE] year-old male, readmitted to the facility on [DATE] with a diagnosis which included absence of right leg below knee. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a need to alter treatment significantly for 1 of 4 residents (Resident #1) reviewed for notification of changes. The facility failed to notify Resident #1's responsible party of her doppler study results of the lower extremities (noninvasive test that can be used to measure the blood flow through the major blood vessels in the legs), gangrene (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) to the right lower extremity, or the need for consultation with a vascular surgeon. This failure could place residents at risk of their responsible parties not being notified or involved in their plan of care.

Inspectors wroteBased on interview and record review the facility failed to facilitate resident and family participation in the care planning process for 4 of 15 residents (Resident #15, Resident #17, Resident #21, and Resident #28) reviewed for care plans. The facility failed to notify and invite Resident # 17's responsible party to care plan meetings. The facility failed to ensure Resident # 15, Resident #21, Resident #28 and their representatives were invited to their care plan meetings. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to effectively reseal, label and date frozen food items. 4) Dietary staff failed to store thawed raw meat below ready to eat foods. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure assessments accurately reflected the resident status for 1 of 15 residents (Resident #34) reviewed for MDS assessment accuracy. The facility failed to ensure Resident #34's anticoagulant (blood thinner) use was accurately coded on his quarterly MDS assessment dated [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents (Resident #34) reviewed for PASRR. The facility failed to refer Resident #34 for PASRR review following new mental illness diagnosis of severe major depression (mood disorder that causes persistent sadness and loss of interest) on 07/17/23. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 3 medication carts (nurse medication cart) reviewed for medication storage. LVN C failed to ensure the facility nurse medication cart was locked when it was left unattended when she went in Resident #31's room to check her blood sugar for insulin administration. This failure could place residents at risk of injury and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #'s 34 and 27) reviewed for hospice services. The facility failed to obtain Resident #34's and Resident #27's most recent updated hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 3 of 15 residents (Resident's #6, #7, and #16) reviewed for accuracy of medical records. 1. The facility did not ensure Resident #16's OOH-DNR was signed at the bottom by the witnesses. 2. The facility did not ensure Resident #6's signed her OOH-DNR. 3. The facility failed to ensure Resident #7's OOH-DNR had a license number, printed name, and date for the physician's statement. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 4 of 15 residents (Resident's #297, #147, #4, and #7) reviewed for comprehensive assessment and timing. 1. The facility did not ensure Resident #297's admission MDS assessment was completed within 14 days of admission. 2. The facility failed to complete Resident #147's admission MDS assessment with 14 days of admission. 3. The facility failed to complete an admission MDS assessment after Resident #4 was discharged returned not anticipated and readmitted to the facility. 4. The facility failed to complete Resident #7's admission MDS assessment within 14 days of admission. These failures could place residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 2 of 15 residents (Resident #4 and Resident #19) and 1 of 1 meal (lunch meal) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature or taste to residents who complained the food was not hot and did not taste good. The facility failed to ensure [NAME] G followed the recipe for pureeing the garlic cheese biscuits for four residents on puree diet. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Hair restraints were worn appropriately by dietary staff. 3. The deep fryer was free of grease build up. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #9, and #18) reviewed for resident rights. The facility did not ensure CNA E treated residents with dignity and respect by referring to them as feeders. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to respect the right to personal privacy for 1 of 1 nurses' station reviewed for privacy. The facility failed to ensure RN L communicated with the hospice company in a private and confidential manner. This failure could place residents at risk of diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, 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, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 15 residents (Resident #4) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #4's edema (swelling) to both legs. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 15 (Resident #4) residents reviewed for quality of care. The facility failed to provide wound care for Resident #4 per the physician's orders. This failure could place residents of risk for not receiving appropriate care and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 16 residents reviewed for respiratory care. (Resident #42). The facility failed to properly store Resident #42's respiratory equipment. The facility failed to change Resident #42's HHN equipment weekly per policy. These failures could place residents at risk of respiratory infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 16 residents (Resident #42) reviewed for medication storage. 1. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #42 had 3 packages (each contained 1 dose vial) of Ipratropium-Albuterol Solution 0.5-2.5 mg in 3 ml (used to open airways to make breathing easier) on top of his bedside table. These failures could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.

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 1 of 6 staff (CNA K) reviewed for infection control. The facility failed to ensure CNA K changed gloves and performed hand hygiene while providing incontinent care to Resident #2. This failure could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 4 halls (Hall 2) reviewed for environment. The facility did not ensure the floor and walls, on Hall 2, were cleaned and free of marks or debris. The facility did not ensure the floor, on Hall 2, was repaired. These failures could place the resident at risk for decreased quality of life and infection due to unsanitary conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #11) reviewed for discharge MDS assessments. The facility did not ensure Resident #11's discharge MDS assessment was completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.