The Oaks

Inspectors wroteAbbreviations:BIMS- Brief Interview for Mental StatusMDS- Minimum Data SetRP- Responsible PartySSD- Social Services DirectorDON- Director of NursingBased on record reviews and interviews, the facility failed to ensure the resident had the right to participate in the development and implementation of their person-centered plan of care by not inviting the resident and/or responsible party to quarterly care plan meetings for 3 (#1, #2, and #3) of 4 sampled residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the Administrator for 1 (#1) of 4 sampled residents.

Inspectors wroteBased on record reviews, and interviews the facility failed to ensure residents were informed of the risks, benefits and side effects of psychotropic medications for 6 (#19, #38, #25, #30, #43, #5) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications.

Inspectors wroteResident #5: Review of the medical record for sampled Resident #5 revealed an admission date of 02/12/2025. Resident #5 had diagnoses which included shortness of breath, diabetes mellitus, heart disease, anxiety and depression. Review of the quarterly MDS assessment dated [DATE] revealed Resident #5 had a BIMS score of 15, which indicated the Resident had intact cognition for daily decision making. Review of the June 2025 physician's orders dated 02/12/2025 revealed an order for Alprazolam (Xanax) 0.5 mg to be given every 8 hours as needed for anxiety. Review of the June 2025 MAR revealed Resident #5 received Xanax 0.5 mg prn on 06/07/2025. Review of the April 2025 and May 2025 Consultant Pharmacist DRR revealed the following recommendation for Xanax .5 mg every 8 hours prn: [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure adequate supervision and assistive devices to prevent accidents were in place for 1 (#23) of 5 (#5, #11, #14, #23, #30) residents investigated for accidents. The failed practice was evidenced by Resident #23 being identified as an unsafe smoker, she was observed smoking without a smoking apron, and was observed having smoking articles in her possession without direct supervision.

Inspectors wroteBased on record review and interviews the facility failed to ensure the Infection Preventionist, who was responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control.

Inspectors wroteResident #1 Review of the medical record for Resident #1 revealed an admission date of 03/11/2008 with a diagnosis of spastic quadriplegic cerebral palsy. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated that Resident #15 was cognitively intact. Additionally, the MDS documented that Resident #15 was dependent on staff for all activities of daily living. On 06/09/2025 at 9:00 a.m. and 4:50 p.m. revealed Resident #1 was observed in her customized wheelchair with her legs dangling with no support noted to her lower extremities. On 06/10/2025 at 10:10 a.m. and 1:00 p.m. revealed Resident #1 was observed in her customized wheelchair with her legs dangling with no support noted to her lower extremities. Review of the current plan of care revealed no documentation related to Resident #1's non-compliance with the use of the wheelchair leg rests. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure it had sufficient nursing staff with appropriate competencies and skills to provide nursing services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident by having staff fail to follow physician orders for 1 (#38) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications. The failed practice was also evidenced by staff not implementing physician orders in a timely manner for 1 (#23) of 1 (#23) residents investigated for the use of antibiotics.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to obtain laboratory examinations as ordered by the physician for 1 (#43) of 6 (#19, #38, #25, #30, #43, #5) sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (#3) of 3 (#3, #30, and #60) residents investigated for pressure ulcers. The facility failed to prevent pressure ulcers from developing as evidenced by resident #3 having six unidentified pressure ulcers.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide adequate supervision to prevent accidents and ensure the resident's environment remained free of hazards for 1 (#62) of 3 (#31, #37, #62) residents reviewed for safe smoking.

Inspectors wroteBased on observation of the medication pass, review of current physician orders, and interviews, the facility failed to ensure that it is free from medication error rate of five percent or greater by committing 2 errors out 32 opportunities for an error rate of 6.25%.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 (#3 and #37) of 2 (#3 and #37) residents reviewed for Activities of Daily Living (ADL) care. The facility [NAME] to 1) ensure resident hand mitts were changed when dirty and 2) ensure that resident finger and toenails were kept clean and trimmed.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to protect the residents' right to be free from verbal abuse and mental abuse for 2 (#3 and #5) of 4 (#1, #2, #3 and #5) residents reviewed for abuse; evidenced by resident #4 used sexually inappropriate language and gestures toward resident #3 and resident #5. This deficient practice resulted in an actual harm for resident #5, who had moderate cognitive impairment, on 10/18/2023 at 1:15 p.m. when resident #4 made an inappropriate sexual comment and gesture to resident #5. This resulted in resident #5 becoming upset and crying. Resident #5 was assisted to her room and was consoled by staff. While being consoled by staff, Resident #5 remained upset and cried for approximatley10 minutes. [...]

Inspectors wroteBased on record review and interviews the provider failed to ensure all allegations of verbal abuse / mental abuse was reported immediately, but no later than 2 hours after the allegation is made, to the State Survey Agency in accordance with State laws. The facility failed to: 1) report an allegation of verbal abuse and mental abuse to the state agency for 1 (#5) of 4 (#1, #2, #3, and #5) residents reviewed for abuse; and 2) report an allegation of verbal and mental abuse to the state agency within 2 hours of becoming aware of the abuse within 2 hours of becoming aware of the abuse situation, for 1 (#3) of 4 (#1, #2. #3, and #5) residents reviewed for abuse.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (#1) of 5 (#1 - #5) sampled residents. The facility failed to thoroughly investigate resident #1's falls and implement appropriate and new interventions following each fall.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide a resident the right to participate in the development and implementation of his or her person-centered plan of care for 1 (#1) of 5 (#1 - #5) sampled residents. The facility failed to inform resident #1 prior to rearranging the furniture in her room.

Inspectors wroteBased on observation and interview, the facility failed to ensure that maintenance services were provided to maintain a safe environment for 1 (#19) of 1 (#19) sampled residents investigated for environmental issues. The facility failed to ensure Resident #19's bathroom flooring surface was not broken. On 07/10/23 09:53 a.m., an observation of resident #19's bathroom revealed there were circular patterns on the floor's surface that surround floor drain. Further observation revealed the areas that were not intact. Further observation revealed the areas on the floor were unevenly broken. On 07/11/2023 at 1:50 p.m., S2 Maintenance Supervisor was notified of the findings regarding resident #19's bathroom flooring being unevenly broken around the floor drain. [...]