The Oaks Rehabilitation and Healthcare Center

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to revise the comprehensive care plan to reflect actual falls with interventions for one (1) of four (4) sampled residents. Resident #1.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the environment remained as free of accident hazards as possible as evidenced by failure to investigate an initial fall, implement interventions to prevent recurrence, and ensure the resident's bed was maintained in a low position for one (1) of four (4) residents reviewed for accidents.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure bed rails were assessed for clinical indication, safety, and resident need and failed to obtain informed consent for bed rail use for one (1) of four (4) sampled residents. Resident #1Findings Include:A review of the facility's policy Proper Use of Bed Rails, dated 11/7/25, revealed, .It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Resident Assessment.2. The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. 3. The resident assessment must also assess the resident's risk from using bed rails. [...]

Inspectors wroteBased on staff interview, record review, facility investigation and facility policy review, the facility failed to implement its abuse prevention policy when Licensed Practical Nurse (LPN) #2 did not immediately notify the Administrator or designee of an abuse allegation for one (1) of 3 sampled residents, Resident #1. Findings Include: A review of the facility's policy, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation dated 10/14/2025, revealed, .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment.are reported immediately to the Administrator of the facility. Compliance Guidelines.8Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation. When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated 1. [...]

Inspectors wroteBased on observations, staff and resident interviews, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) plan as evidenced by one (1) re-cited deficiency originally cited in January 2024 on an annual recertification survey. This is for (1) of seven (7) cited deficiencies on the current annual recertification survey.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide reasonable accommodation of needs by not individualizing a blind resident's call system for one (1) of nineteen (19) sampled residents (Resident #17).

Inspectors wroteBased on observations, interviews, record reviews, and facility policy reviews, the facility failed to ensure ongoing assessment and documentation of skin integrity for one (1) of two (2) residents reviewed for wound care. Specifically, Resident #35, who was at high risk for skin breakdown, did not receive Weekly Skin Integrity Reviews as required by facility policy and clinical standards of practice. Findings Include: A record review of the facility's policy Skin Evaluation with a revision date of 4/1/2017 revealed a license nurse will complete a total body evaluation on each resident weekly and document the observation on the Skin Evaluation form. [...]

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review the facility failed to provide perineal (peri) care in accordance with professional standards of care for one (1) of two (2) peri care observations (Resident #35).

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to properly dispose of food and to seal open foods in bags to prevent the possibility of a foodborne illness for one (1) of two (2) kitchen tours.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide perineal (peri) and wound care in a manner to prevent the possibility of spreading infection for two (2) of five (5) observations of care (Resident #35).

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure a Resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one (1) nineteen (19) sampled residents. Resident #57.

Inspectors wroteBased on interviews, record review, the facility's investigation, and facility policy review, the facility failed to ensure residents' right to be free from physical and verbal abuse when Certified Nurse Aide (CNA) 1 was reported by two staff members (CNA #2 and CNA #3) to have physically abused Resident #1 on 3/7/25 at 6:45 AM and verbally abused Resident #2 date/time unknown, both vulnerable residents, and the facility did not take immediate protective action for two (2) of four (4) sampled residents. Additionally, the Administrator was not informed of the allegation until 3/17/25, at which time CNA #1 was suspended. This left residents vulnerable for ten (10) days after the abuse was initially witnessed by staff. The facility's failure to provide immediate protective action placed these residents and other vulnerable residents at risk for serious harm, injury, impairment, or death. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for two (2) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) #1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not intervene to prevent the violation of the residents' rights to be free from abuse. The facility's failure to intervene and immediately report to the Administrator placed Resident #1, Resident #2 and other residents at risk for similar abuse including the risk for serious harm, injury, impairment, or death. [...]

Inspectors wroteBased on interviews, record review, the facility's investigation and facility policy review, the facility failed to report abuse within the required two (2) hour timeframe (Resident #1 and #2) and failed to submit a completed investigation for an allegation of abuse (Resident #3) to the State Agency (SA) within five (5) working days for (3) of four (4) sampled residents. Resident #1 was physically abused on 3/7/25 by Certified Nurse Aide (CNA) 1 which was witnessed by CNA #3 and Resident #2 was verbally abused by CNA #1 and was witnessed by CNA #2. CNA #1 and CNA #2 did not immediately report the abuse, until 3/17/25, which was ten (10) days after the first instance of abuse was witnessed. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for one (1) of four (4) care plans reviewed, Resident #1.

Inspectors wroteBased on interview, record review, and facility statement review the facility failed to ensure sufficient nursing staff was available to meet the needs of residents resulting in a resident being left soiled all night for one (1) of five (5) sampled residents.

Inspectors wroteBased on staff and resident interviews and review of the Facility Assessment, the facility failed to ensure all required elements were included in the Facility Assessment, including specific staffing needs by shift, a plan for recruitment and retention of staff, and contingency planning that does not require activation of the facility's emergency plan for three (3) of three (3) days of a complaint survey. Findings Include: A review of the document titled Facility Assessment Tool revealed that 8-10 Licensed Practical Nurses (LPNs), 16-18 Nurse Aides, 5 non-nursing administrative employees, 2 Social Services workers, 1 contracted Dietitians, and 10 contracted dietary workers with zero respiratory workers were identified as sufficient to meet the facility's staffing needs in a 24-hour period. [...]

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure daily nurse staffing information was posted in a visible and accessible location for two (2) of three (3) survey days. This failure limited residents, family members, and the public from accessing required staffing information and impeded transparency regarding facility staffing levels. On February 24, 2025 at 2025 at 2:00 PM, in an interview Licensed Practical Nurse (LPN)# 2, revealed that staffing is normal posted near the copier room in a glass case. LPN # 2 revealed after observation that there was no staffing posted. On February 25, 2025 at 2025 at 10:00 AM, in an interview LPN#3, revealed that staffing is normal posted near the copier room in a glass case. LPN# 3 confirmed after observation there was no staffing posted. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to honor a resident's right to refuse treatment when Resident #1, who was a hospice patient and had a signed Do Not Resuscitate (DNR) Physician's Order, received cardiopulmonary resuscitation (CPR) by facility staff for one (1) of four (4) residents reviewed. Resident #1 Resident #1's medical record had conflicting information regarding the code status of the resident and caused Resident #1 to receive CPR by facility staff for 25 minutes, which was against his wishes and the Physician's Order. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the facility received a signed DNR Physician's Order. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop comprehensive care plan interventions regarding Advanced Directives for one (1) of four (4) residents reviewed. Resident #1 The facility's failure to develop comprehensive care plan interventions caused Resident #1 to receive cardiopulmonary resuscitation (CPR) by facility staff which was against his wishes and the Physician's Order. Resident #1 received CPR for 25 minutes. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE]. The State Agency (SA) notified the facility's Administrator of the IJ on [DATE] at 1:40 PM and provided the Administrator with the IJ templates. This situation placed Resident #1 and other residents with DNR orders at risk for the likelihood of serious injury, serious harm, serious impairment or death. [...]

Inspectors wroteBased on observation, interviews, record review and facility statement review the facility failed to provide sufficient nursing staff resulting in residents not receiving showers and nail care for five (5) of seven (7) sampled residents and had the potential to affect all 77 residents residing in the facility. Resident #69, Resident #229, Resident #40, Resident #47 and Resident #59. Findings Include: Record review of a statement typed on facility letterhead, undated, and signed by the Administrator, revealed, The staffing policy for (Proper Name of Facility) is to staff according to census and acuity. Review of the provider's [NAME] reporting data revealed the facility triggered excessively low weekend staffing for four (4) quarters and triggered for one star rating for the first and fourth quarters: [...]

Inspectors wroteBased on staff, resident and family interview and record review the facility failed to ensure residents' individual preference were followed related to the type of bath they preferred for one (1) of eighteen (18) sampled residents.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to provide written notification of transfer to a resident or the Resident Representative (RR) for one (1) of three (3) closed records reviewed. (Resident #74) Findings Include: A review of the facility's Policies and Procedures, revised 10/24/2022, revealed, Subject: Transfer/Discharge Notification & (and) Right to Appeal .Policy: Transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to Federal and/or State regulatory requirements .Procedure .Notice before Transfer: Before a center discharges a resident the center must: Notify the resident and resident representative(s) of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand) . [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure a resident's nails were cleaned and clipped for one (1) of eighteen (18) sampled residents. Resident #69.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to maintain proper placement of a urinary catheter bag to prevent the possible spread of infection for one (1) of three (3) residents observed with urinary catheters. Resident #228.

Inspectors wroteBased on staff and resident interviews, record review, facility investigation, and policy review the facility failed to protect a resident from verbal abuse for one (1) of six (6) residents sampled.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to protect the resident's right to be free from verbal abuse for six (6) of 18 residents reviewed for abuse. Resident #15, Resident #23, Resident #27, Resident #35, Resident #49, and Resident #63 Findings Include: Review of the facility policy, Abuse Prohibition Policy & Procedures revised 11/28/2017, revealed, Policy: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property .Employees of the center are charged with a continuing obligation to treat residents so they are free from abuse, neglect mistreatment, and/ or misappropriation of property against any resident .Definitions: [...]

Inspectors wroteBased on interviews, record reviews, and facility policy review the facility failed to make prompt efforts to resolve a grievance for one (1) of 18 residents sampled residents. Resident #57 Findings Include: A record review of the facility's Clinical Guideline-Complaint/Grievance document with a revision date of 8/9/2018, revealed, Overview: The intent of this guideline is to support each resident's right to voice grievances; and to assure that after receiving a complaint/grievance, the center actively seeks a resolution and keeps the resident appropriately apprised of its progress toward resolution . On 06/20/22 at 11:40 AM, during an interview with Resident #57, she stated that she had a guitar that she kept in a dark brown case that had come up missing several months ago. She told the staff that it was missing, and she was told they were going to look for it. [...]

Inspectors wroteBased on staff interviews, record reviews, and facility policy review, the facility failed to initiate a care plan with goals and interventions for one (1) resident with new pressure ulcers to left gluteal fold for one (1) of 18 cares plans reviewed.

Inspectors wroteBased on staff interviews, record reviews, and facility policy review the facility failed to revise a care plan when treatment was changed to the right foot and when wounds were resolved to the right dorsal foot, right metatarsal head fifth, right calcaneus, and right metatarsal head first, for one (1) of 18 cares plans reviewed.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure physician orders related to wound care were transcribed into the medical record for one (1) of 18 residents sampled. Resident #66 Findings Include: A record review of the facility's policy and procedures with the Subject listed as Physician Orders and a revised date of 03/03/2021, revealed, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record . A record review of Resident #66's June 2022 Order Summary Report revealed there were no current physician orders for a treatment to the newly identified pressure ulcers on the left gluteal fold or to the existing venous wound on the right top foot/lower leg. [...]

Inspectors wroteBased on observation and interviews, the facility failed to store food in accordance with professional standards for food service safety, related to orange juice stored past the discard date in one (1) of two (2) the medication rooms observed. Findings Include: On 06/21/22 at 10:40 AM, during an observation of the medication room with Licensed Practical Nurse (LPN) #3, the State Agency (SA) observed a refrigerator located inside the medication room. There were five (5) 4-ounce containers of orange juice inside the refrigerator. Three (3) of the orange juice containers had an expiration date of 12/21 and two (2) had an expiration date of 2/22. All 5 containers of orange juice were stored in the refrigerator past the discard date. [...]