The Oaks Care Center

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff sanitized reusable medical equipment between each resident use, and performed hand hygiene after direct resident contact. Findings: Review of facility policy on 01/06/2026 at 1:30 p.m. titled Hand Hygiene Policy and Procedure dated 07/01/2020 revealed in part.Policy: Hand Hygiene shall be performed: (3) Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. (12) Before as appropriate and after coming in contact with a resident's intact skin (e.g. when taking a pulse, blood pressure, and lifting a resident). Observation of medication administration on 01/06/2026 from 8:20 a.m. until 8:45 a.m. revealed S3LPN used a wrist blood pressure cuff to monitor the blood pressure of multiple residents. Observation revealed the blood pressure cuff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident's rights for 2 (Resident #10 and Resident#12) of 20 Sampled Residents. The facility failed to: 1. Develop a focus of weight loss for Resident #10; and2. Develop a focus of depression for Resident # 12. Findings: Resident #10 Review of Resident #10's electronic health record revealed an admission date of 08/21/2020 with diagnoses which included: Alzheimer's disease, Schizoaffective Disorder, Dementia, Anxiety, Severe Intellectual Disabilities, Chronic Kidney Disease, Unspecified Severe Protein-Calorie Malnutrition, Dysphagia, and Vitamin Deficiency. Review of Resident #10's Quarterly MDS with an ARD of 11/04/2025 revealed that a BIMS was not conducted due to Resident #10 being rarely/never understood. Resident #10 was dependent on staff for all ADLs. Review of Resident #10's weight record revealed the following which represented a significant weight loss: 06/06/2025: 102.1 lbs. 07/08/2025: 98.8 lbs.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. Total sample size was 20. Findings:Review of Resident #73's electronic health record revealed an admission date of 01/03/2017 with diagnoses which included: Chronic Obstructive Pulmonary Disease, Mild Protein-Calorie Malnutrition, Generalized Osteoarthritis, Mild Cognitive Impairment, Dementia, Gout, and Encounter for Prophylactic Measures. Review of Resident #73's Quarterly MDS with an ARD of 10/09/2025 revealed a BIMS score of 1 indicating severe cognitive impairment. Resident #73 had bilateral upper extremity functional limitations in range of motion. Review of Resident #73's Physician's Order dated 08/04/2025 revealed in part. rolled gauze or hand roll to right hand every shift. Multiple observations of Resident #73 revealed that no rolled gauze or hand roll was present in Resident #73's hand. Observations occurred on the following dates and times:01/05/2026 at 1:30 p.m.01/06/2026…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure services were provided to residents according to accepted standards of clinical practice for 2 (Resident #97 and Resident #102) out of a total sample of 30 residents. The facility failed to notify the physician when: 1. Resident #102 had blood glucose levels greater than 451 mg/dL as ordered. 2. Resident #97 had an unwitnessed fall. Findings: Review of a facility policy titled Change in Condition Policy and Procedure dated 08/27/2018 revealed in part . Procedure: 2. The licensed nurse will assess the resident and note any signs and symptoms, including physical and mental changes in condition. Assessment may include but is not limited to: physical assessment findings, vital signs, blood glucose, oxygen saturation, etc. The licensed nurse will document assessment findings in the electronic medical record. 3. The resident's primary physician or designated alternate will be contacted promptly of a significant change in the resident's status. a. If unable to contact primary physician or designated alternate, the medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

FACILITY Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to ingredients and portion size to ensure the nutritional adequacy of the meal for all 9 residents who received a puree diet. Findings: Review of the facility's policy titled: Preparation and Service of Pureed Diets read in part .Procedure 5: Follow recipes provided .Procedure: 6.A food thickener may be added to pureed foods to thicken the food to its desired consistency. In an interview during the initial kitchen tour at 8:43 a.m. on 09/16/2024, S3 Dietary Manager stated the facility had 9 residents being served a puree diet. In an observation on 09/16/2024 at 9:13 a.m., S4 Dietary [NAME] prepared puree pot roast and placed ½ of a roast in the blender with 6 pieces of bread, and approximately 1/2 pan of water in the blender to puree the roast. In an observation at 9:20 a.m., S4 Dietary [NAME] added 3 small cartons of whole milk to the 40 yam patties she placed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#109) of 30 sampled residents. The facility failed to implement appropriate infection control precautions for Resident #109. Findings: Review of the facility's policy and procedure dated 04/01/2024, and titled Enhanced Barrier Precautions read in part . Policy: To follow CMS guidelines related to Enhanced Barrier Precautions, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. i. Wounds generally include chronic wounds, not short-lasting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 4 (Resident #4, Resident #15, Resident #63, and Resident #70 ) of 4 sampled residents with MDS record over 120 days old. Findings: Review of the facility MDS transmission reports for Resident #4, Resident #15, Resident #63, and Resident #70 revealed the MDS Assessments with ARD of 07/18/2023 for all the above residents had not been transmitted until 08/17/2023. Interview on 08/23/2023 at 11:10 a.m. with S11 LPN/MDS Team Leader and S12 LPN/MDS Coordinator confirmed the above findings. S11 LPN/MDS Team Leader and S12 LPN/MDS Coordinator denied any technological issues that may have hindered transmission of the noted assessments. S11 LPN/MDS Team Leader revealed assessments should have been transmitted within 14 days of completion and had not been.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #19) of 36 sampled residents by failing to ensure she was free of facial hair. Findings: Review of Resident #19's medical records revealed she was admitted to the facility on [DATE] with diagnoses which included: Hyperlipidemia, Unspecified Mood disorder, Athsclerotic Heart Disease, Type 2 Diabetes Mellitus, Essential Hypertension, Unspecified Dementia, Alzheimer's disease and Anxiety Disorder. Review of Resident #19's Quarterly MDS with an ARD of 05/19/2023 revealed a BIMS score of 14 (indicating intact cognition). Resident #19 required physical assistance with 1-person physical assist for bed mobility, personal hygiene, bathing and toilet use. An interview and Observation on 08/21/2023 at 10:52 a.m. revealed Resident #19 sitting in dining room waiting for lunch with long facial hair on her chin and lip. Interview with Resident #19 revealed that she would like for her face to be shaved. An Observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the Facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (Resident #47) of 31 sampled Residents. The facility failed to provide a diet according to Resident #47''s food preferences. Findings: Review of Resident #47's medical record revealed an admit date of 11/04/2020 with diagnoses which included: Morbid Obesity, Functional Dyspepsia, Peripheral Vascular Disease, Atherosclerosis of Native Coronary Arteries and Bilateral Amputee. Review of a Quarterly MDS assessment with an ARD of 07/25/2023 revealed Resident #47 had a BIMS score of 15 indicating intact cognition. Review of August 2023 Physician orders revealed Resident #47 was on a regular no added salt, no red meats and no fried foods diet. Review of Resident #47's dietary card revealed a regular no added salt diet with dislikes of: cream corn, pork roast, mashed potatoes, pork ham, pork chop, pulled pork, cheese, scallop potatoes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to ensure the bathroom wall and door in Room A were in good repair. Findings: Observation on 08/21/2023 at 12:38 p.m. of the resident bathroom in Room A revealed several small holes in the wall near the commode with 2 exposed screws underneath the grab bar. Observation of the inside of the bathroom door revealed the door appeared shredded across the middle. Observation on 08/24/2023 at 10:30 a.m. of the resident bathroom in Room A revealed several small holes in the wall near the commode with 2 exposed screws underneath the grab bar. The inside of the bathroom door appeared shredded across the middle of the door. Observation of Room A bathroom on 08/24/2023 accompanied by S2 DON revealed the above concerns remained present. Interview at the time of observation confirmed the door was peeling and damaged across the middle and lower corners. Two exposed screws were present below the wall grab bar and several small holes were present in the wall beside the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 1 (Resident #81) of 1 resident sampled for misappropriation, in a total sample of 36 residents. The facility failed to prevent misappropriation of Resident #81's funds by S10 CNA. Findings: Review of the facility abuse policy revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. No one shall abuse a resident. This policy applies to facility staff, other residents, family members or resident representatives, and anyone else present in our facility. 7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent. Review of Resident #81's clinical record revealed an admit date of 08/01/2022 with diagnoses that included Syringomyelia, Syringobulbia, Paraplegia, Neuromuscular Dysfunction of Bladder, and Pressure Ulcer of Left Buttock. Review of Resident #81's Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #46 and Resident #211) of 2 residents reviewed for respiratory care. The facility failed to: 1. Provide humidification in accordance to the resident person centered plan of care 2. Ensure respiratory equipment was properly stored Findings: Resident #46 Review of Resident #46's medical records revealed a diagnoses of Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Heart Failure, and Anxiety Disorder. Review of Resident #46's care plan with a review date of 09/27/2023 revealed Resident# 46 required oxygen therapy due to Chronic Obstructive Pulmonary Disease with facility interventions to provide humidification to oxygen therapy. An interview on 08/21/2023 at 11:30 a.m. with Resident #46 revealed she requested the facility add humidification to her oxygen concentrator multiple times because her nose became dry and irritated with oxygen usage without humidification. Resident #46 stated someone notified her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 113 Residents who receive meals prepared by the facility kitchen. Findings: Review of the facility's policy titled: Standardized Recipes read in part . Standardized recipes are used in preparation of food for control of quality, quantity, and uniformity of product. 2. A standardized recipe includes the following information: Yield and portion size. Review of the facility's policy titled: Portion Control read in part . Menus shall reflect standardized portion sizes to ensure nutritional adequacy of the diets, control production, and enhance food cost control efforts. 1. The established portion sizes for specific menu items are listed on the posted menu modification. 3. Employees are expected to follow established portions size for all menu items unless otherwise altered for nutrition care purposes or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 113 residents that received meals prepared by the kitchen. Findings: Review of the facility's policy titled: Cleaning and Sanitizing Equipment read in part . All equipment is kept clean and food contact surfaces are cleaned and sanitized. Observation of the facility's kitchen on 08/21/2023 at 8:25 a.m. accompanied by S3 Dietary Manager revealed: The kitchen's microwave was unsanitary with dried food splattered on the top and bottom. The dry food storage area contained 1 carton of thickened cranberry juice that had an expiration date of 07/28/2023 on the shelf for use. Interview with S3 Dietary Manager on 08/21/2023 at 8:35 a.m. confirmed the above findings. S3 Dietary Manager stated the microwave needed to be cleaned, and the shelf should not contain any expired items.