Inspection Reports for
Oak Knoll Health and Rehabilitation, LLC

The complaint investigation involved report number AL00046804 regarding verbal abuse by CNA #4 and report number AL00047459 regarding RI #1 possessing lighters against facility policy. The verbal abuse was substantiated with CNA #4 admitting to cursing at the resident. The possession of lighters was confirmed on two occasions, with safety concerns noted.

The facility failed to prevent verbal abuse of RI #1 by CNA #4, who admitted to cursing at the resident. Additionally, the facility failed to ensure that RI #1 did not possess lighters on two separate occasions, violating the supervised smokers policy and posing a safety risk.

The investigation was triggered by complaint/report numbers AL00046804 related to verbal abuse and AL00047459 related to possession of lighters by RI #1. The verbal abuse complaint was substantiated with CNA #4 admitting to cursing at RI #1. The possession of lighters was confirmed on two occasions, with the resident having lighters on 01/28/2024 and 02/09/2024.

The facility failed to prevent verbal abuse when CNA #4 cursed at RI #1 during an argument over a cigarette lighter. Additionally, the facility failed to ensure that RI #1 did not possess lighters on two separate occasions, violating the facility's supervised smokers policy and posing a fire risk.

The complaint investigation was triggered by an incident on 05/04/2023 when two armed former employees entered the facility through a broken door, held staff at gunpoint, stole narcotic medications for 26 residents and an employee's cell phone. The investigation confirmed the door was broken for over a year and door codes were not changed after terminations, allowing unauthorized access.

The facility failed to maintain a safe environment by not repairing a broken exterior door for over a year and not changing door entry codes after employee terminations, allowing unauthorized armed individuals to enter and steal medications. The Master Code was not changed until 05/16/2023, after the incident. These failures placed all 87 residents at immediate jeopardy of serious harm.

The complaint investigation was triggered by an incident on 05/04/2023 where two armed former employees entered the facility through a broken exterior door, held staff at gunpoint, stole narcotic medications for 26 residents and an employee's phone. The facility was found to have failed to secure the door and change door codes after terminations. The immediate jeopardy began on 05/04/2023 and was removed on 05/19/2023 after corrective actions.

The facility failed to maintain a safe environment by not repairing a broken exterior door for over a year and not changing door entry codes after employee terminations, allowing unauthorized armed individuals to enter the facility. The Master Code was not changed until 05/16/2023, after the incident and survey team entry. These failures placed 87 residents at immediate jeopardy and resulted in theft of medications and property.

The complaint investigation was triggered by an incident on 05/04/2023 where two former employees, armed and masked, entered the facility through a broken exterior door and used a keypad code known to them to access resident care areas. They held staff at gunpoint, stole narcotic medications for 26 residents, and an employee's cell phone. The investigation confirmed the door was broken for over a year and door codes had not been changed after employee terminations. The immediate jeopardy was removed on 05/19/2023 after corrective actions.

The facility failed to maintain a safe environment by not repairing a broken exterior door for over a year and failing to change door entry codes, allowing unauthorized armed individuals to enter and steal medications. This placed all 87 residents in immediate jeopardy. The Administrator admitted knowledge of the broken door and failure to change the master code promptly after the incident.

The facility failed to maintain a safe environment by not repairing a broken exterior door for over a year and failing to change door entry codes, allowing unauthorized armed entry. This resulted in theft of narcotic medications and placed all residents at immediate jeopardy. The Administrator admitted knowledge of the broken door and failure to change the master code promptly after the incident.

The facility failed to develop and implement comprehensive care plans for residents receiving dialysis, failed to ensure proper communication with dialysis centers, and did not consistently document fluid intake. Medication storage deficiencies were noted with expired medications found. Dietary services failed to follow recipes and proper food handling procedures, and the kitchen environment was unsanitary. Infection control lapses were observed with staff not wearing required PPE in isolation rooms.

The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents receiving dialysis, inadequate communication with dialysis centers, improper medication storage including expired medications, failure to follow dietary menus and recipes especially for pureed diets, unsanitary kitchen conditions, and failure to adhere to infection prevention protocols including PPE use in isolation rooms.

The facility failed to ensure licensed staff did not leave medications unattended at a resident's bedside, posing potential harm. Specifically, a licensed practical nurse left medications unattended while obtaining supplies, which could lead to medication errors or harm to residents.

The facility failed to ensure licensed staff did not leave medications unattended at a resident's bedside, posing potential harm. Specifically, a licensed practical nurse left medications unattended at Resident Identifier #17's bedside while retrieving supplies.

The complaint investigation focused on incidents involving resident falls, inadequate toileting assistance, and improper denture care. The fall was substantiated as the bed wheels were not locked during care. The toileting deficiency was confirmed by interviews and care plan review. The denture care deficiency was observed over multiple days and confirmed by staff interviews.

The facility failed to ensure resident safety by not securing bed wheels during care, resulting in a resident fall; failed to provide timely toileting assistance to maintain bladder function for a resident; and failed to maintain proper denture hygiene, with dentures soaking in dirty solution over multiple days.

The facility was found deficient in ensuring resident safety related to bed wheel locking which led to a resident fall, failure to provide appropriate toileting assistance to maintain bladder function, and inadequate denture cleaning practices that posed infection risks.