Inspection Reports for
The Oaks Rehabilitation and Healthcare Center

The complaint was substantiated. The investigation confirmed that the CNA made inappropriate comments to Resident #1 and that LPN #2 failed to report the allegation immediately. Corrective actions were taken including suspension and re-education of involved staff.

The facility failed to immediately notify the Administrator or designee of an abuse allegation by Licensed Practical Nurse (LPN) #2. The CNA admitted to making a joking comment threatening to spank the resident if he used his call light. Corrective actions included suspension of the CNA and LPN #2, in-service training on abuse reporting and professional communication, and a full body audit of the resident.

The facility was found deficient in multiple areas including failure to individualize a blind resident's call system, inadequate weekly skin integrity assessments, improper perineal care, poor food storage practices, ineffective quality assurance and performance improvement (QAPI) plan, and lapses in infection prevention and control practices.

The facility failed to ensure that Resident #57, who was unable to perform ADLs independently, received necessary grooming and personal hygiene care, including facial hair trimming and toenail care. Interviews and observations confirmed the resident had long facial hair and toenails that were overdue for trimming.

The complaint investigation was triggered by allegations of physical abuse of Resident #1 and verbal abuse of Resident #2 by CNA #1, witnessed by other staff. The abuse was not reported until 10 days later. Additionally, the facility failed to submit a timely investigation report for verbal abuse allegations involving Resident #3. The allegations were substantiated based on staff statements and investigation.

The facility failed to protect residents from abuse, failed to intervene and report abuse immediately, and failed to submit a timely investigation report to the State Agency. Immediate Jeopardy was identified due to physical abuse of Resident #1 and verbal abuse of Resident #2 by CNA #1, with delayed reporting and intervention by staff. The facility implemented corrective actions and the Immediate Jeopardy was removed.

The complaint investigation found substantiated issues related to insufficient nursing staff on the night of February 23, 2025, causing a resident to remain soiled overnight, and failure to post required nurse staffing information on February 24 and 25, 2025.

The facility failed to provide adequate nursing staff during the overnight shift on February 23, 2025, resulting in a resident being left soiled all night. Additionally, the facility failed to post daily nurse staffing information for two of three survey days and did not include required elements in the Facility Assessment related to staffing by shift, recruitment, retention, and contingency planning.

The complaint investigation was substantiated. The facility was found to have failed to honor the resident's DNR order, resulting in CPR being administered for 25 minutes contrary to the resident's wishes. Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to honor Resident #1's DNR order due to conflicting documentation between the hard chart and electronic health record, causing CPR to be administered against the resident's wishes. The facility also failed to develop a comprehensive care plan reflecting the resident's advanced directives in a timely manner. Corrective actions were implemented, including audits, education, and monitoring, leading to removal of Immediate Jeopardy status.

The facility was found deficient in honoring residents' bathing preferences, providing written transfer notifications, ensuring proper nail care, maintaining catheter bag placement to prevent infection, and staffing levels sufficient to meet resident needs. These deficiencies affected multiple residents and had the potential to impact all 77 residents.

The complaint was substantiated. The housekeeper verbally abused Resident #1 on 10/23/23 by entering his room without permission and arguing with him. The facility investigated promptly, placed the employee on leave, and provided abuse training. The deficiency was corrected prior to the State Agency's entrance on 11/27/23.

The facility failed to protect Resident #1 from verbal abuse by a housekeeper who entered the resident's room without permission and argued with him. The housekeeper was placed on leave and subsequently left employment. The facility conducted an immediate investigation and provided in-service training on abuse.

The complaint involved an incident on or around 8/5/23 or 8/6/23 where Resident #2 hit Resident #1. The facility staff failed to report the incident to the State Agency and did not complete a thorough investigation. Interviews with multiple staff confirmed the failure to report and incomplete investigation.

The facility failed to timely report suspected resident on resident abuse to the State Agency and did not conduct a thorough investigation of the abuse allegations. Staff were aware of the incident but did not follow policy requirements for reporting and investigation.

The complaint investigation included substantiated findings that the facility failed to resolve a grievance about a missing guitar, failed to protect residents from verbal abuse, failed to develop and revise care plans for pressure ulcers, failed to transcribe wound care orders, and failed to properly store expired food.

The facility failed to promptly resolve a grievance about a missing guitar for one resident, failed to protect six residents from verbal abuse by a staff member, failed to develop and revise care plans for pressure ulcers for one resident, failed to transcribe wound care physician orders for one resident, and failed to properly store expired orange juice in the medication room.