The Oaks

Inspectors wroteBased on record review, observations and staff interviews, the facility dietary staff failed to demonstrate competency with monitoring the chemical sanitization level for the low temperature dish machine by not performing testing at least once per shift which could affect 111 of the 111 residents.

Inspectors wroteBased on observation and staff interviews, the facility failed to 1) to maintain the minimum chemical sanitization level of the low temperature dish machine according to the manufacturer's recommendations 2) clean the convection ovens, the fryer, the toaster, steamer, stove and plate warmer for 3 of 3 observations 3) allow cooking pans and dishes to completely dry prior to assemblage and stacking for two of two observations, 4) remove cracked and dirty plates prior to meal service for 1 of 1 observation and clean 2 of 3 meal carts. These practices had the potential to affect food served to residents. 1. The manufacturer program brochure for the low temperature dish machine was reviewed and specified the minimum chemical sanitizer rinse requirements were 50 parts per million (ppm) of chlorine. An observation and interview with the Dietary Manager (DM) were conducted on 8/11/25 at 9:46 AM. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure debris was removed from behind the dumpsters for 3 of 3 dumpsters observed. This practice had the potential to attract pests and rodents. An observation of the dumpster area was conducted on 8/11/25 at 10:04 AM. Behind all 3 dumpsters, used debris items such as straws, cup lids, empty chip bags, and empty milk cartons were observed. An interview was conducted with the Maintenance Director on 8/11/25 at 10:07 AM. He stated that he normally picked up debris items in the parking lot, but the dietary department was responsible for the dumpster area. He stated he would grab a shovel and pick up the debris behind the dumpsters. During an interview with the Dietary Manager on 8/12/25 at 9:52 AM, she revealed that the Maintenance Director was responsible for cleaning the dumpster area. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) hours. This was for 1 of 3 Federal Fiscal Year quarters reviewed for sufficient nurse staffing (Quarter 2: January 1-March 31, 2025).

Inspectors wroteBased on record reviews, and staff and resident interviews, the facility failed to honor residents' preference for eating in the dining room for 9 days due to a COVID-19 outbreak when one employee tested positive on 8/2/25 for 3 of 5 residents reviewed for choices (Residents #20, #63, and #110). Review of the facility's policy COVID-19 Response Program last revised August 2025 revealed that the term outbreak was not defined and there was not any instruction for dining activity during an outbreak. The policy did state for the facility to notify the health department of any suspected or confirmed cases. During an observation of the dining room on 8/11/25 at 12:20 PM, there were not any residents eating lunch in the dining room. [...]

Inspectors wroteBased on observations, record review, and resident council member and staff interviews, the facility failed to conduct resident council meetings in a private area for 6 of the 6 resident council meetings reviewed in the last 6 months (2/19/25, 3/19/25, 4/16/25, 5/21/25, 6/18/25, and 7/23/25).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a baseline care plan that addressed the resident's immediate needs within 48 hours of admission for 2 of 30 sampled residents (Residents #51 and #106).

Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility failed to apply compression wraps to Resident #87's legs as ordered. The deficient practice occurred in 1 of 1 resident reviewed for providing services to meet professional standards (Resident #87).

Inspectors wroteBased on record review, observations, and resident, staff and physician interviews, the facility failed to provide ordered physical therapy for a resident with history of stroke and spastic contractures in 1 of 1 resident reviewed for rehabilitation services (Resident #5).

Inspectors wroteBased on observations, and resident and staff interviews, the facility failed to provide a privacy curtain for 2 of 16 rooms on the 200-hall reviewed for privacy (Resident #27 and Resident #40).

Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility failed to ensure accurate medical records regarding the documentation of the application of compression wraps to Resident #87's legs. The deficient practice occurred in 1 of 1 resident reviewed for resident records (Resident #87).

Inspectors wroteBased on record review, and staff and resident interviews the facility failed to provide resolution of Resident Council Meeting grievances for 3 of 3 monthly Resident Council Meetings. The Resident Council had repeated concerns regarding water cups were not filled timely and snacks were not available (2/19/24, 3/18/24, 4/15/24).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to assist a resident in obtaining dentures. This occurred for 1 of 3 residents reviewed for dental services.

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to invite the resident to participate in the care planning process for 1 of 23 residents whose care plans were reviewed (Resident # 78). Findings Included: Resident #78 was originally admitted on [DATE]. The most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact. During an interview on 7/21/24 at 10:45 am, Resident #78 stated he had not been invited to attend a care plan meeting for a long time and that he wanted to be asked to attend his care plan meetings. An interview was conducted with the facility Social Worker on 7/23/24 at 12:22 pm. She indicated Resident #78 had not attended a care plan meeting since August 2022 and was not able to confirm if he had been invited to attend any of his care plan meetings after August 2022. [...]

Inspectors wroteBased on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to provide incontinent care in a safe manner which caused a fall (Resident #29). This was for 1 of 3 residents reviewed for accidents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to secure the urostomy (an opening in the urinary system) tubing per the physician order on 1 of 4 residents observed for urinary catheters (Resident #48).

Inspectors wroteBased on record reviews and staff interviews, the facility failed to provide Registered Nurse (RN) coverage at least 8 consecutive hours a day for 7 out of 72 days reviewed for staffing. The failure to have RN coverage for the facility had a high likelihood of impacting every resident in the facility. The facility also failed to prevent the Director of Nursing (DON) from serving as a charge nurse with a facility census of greater than 60 residents for two days, 8/20/23 and 7/30/23.

Inspectors wroteBased on record review and staff, Medical Director, Nurse Practitioner, and Pharmacist interviews, the facility failed to prevent a significant medication error by failing to administer a prescribed medication for Parkinson's disease at the dose ordered by a physician for 11 of 11 doses administered for 1 of 1 resident (Resident #354) reviewed for medication errors. Findings Included: Resident #354 was admitted to the facility on [DATE]. His cumulative diagnosis included Parkinson's disease (a disease of the central nervous system that affects movements, often including tremors). Physician order dated 8/29/23 read Azilect (a medication used to treat the symptoms of Parkinson's disease) oral tablet 0.5 milligrams (mg) give one tablet by mouth in the morning for Parkinson's disease. The start date was 8/30/23 at 9:00 A.M. [...]

Inspectors wroteBased on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification, complaint, and infection control surveys completed on 7/23/21 and 9/24/21. This was for 2 deficiencies that were cited in the areas of Label/Store Drugs and Biologicals (761) which was cited on 7/23/21 and recited on the current recertification and complaint survey of 9/15/23; and Residents are Free of Significant Medication Errors (760) which was cited on 9/24/21 and recited on the current recertification and complaint survey of 9/15/23. The continued failure of the facility during three federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program (QAA).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities, resulting in a medication error rate of 7.14% for 1 of 3 residents (Resident #354) observed during the medication administration observation.

Inspectors wroteBased on observations and staff interview, the facility failed to properly discard three expired vaccines, Prevnar 20 (Pneumococcal 20-valent Conjugate Vaccine) that were available for use in 1 of 3 medication rooms (100 hall nurse's station).

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to maintain the pull cord of a bathroom call light for 2 of 2 front hall public restrooms.

Inspectors wroteBased on record review and staff interviews, the facility failed to notify the family member and the Long-Term Care Ombudsman in writing when 1 of 3 sampled residents (Resident #253) was discharged to the hospital.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to provide the resident a written notification of the bed hold policy upon a resident's transfer to the hospital for 1 of 3 residents (Resident #253) reviewed for hospitalization.