Allen Oaks Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Allen Oaks Nursing and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 19, 2024

  Based on record reviews, observations, and interviews, the facility failed to ensure a cognitively impaired resident who had a history of wandering, was adequately supervised and not allowed to exit the building without staff knowledge, for 1 Resident (#R7) of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). This deficient practice resulted in an Immediate Jeopardy situation on 06/25/2024 at 3:59 p.m., when Resident #R7, a severely cognitively impaired resident who had a history of wandering, followed visitors out of the building via the front entrance door, and walked into the parking lot unsupervised on 06/25/2024 and 08/03/2024. S1 ADM was notified of the Immediate Jeopardy on 08/16/2024 at 6:50 p.m. […]

• Immediate jeopardy, isolatedF835Aug 19, 2024

  Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 Resident (#R7), of 12 sampled residents (#1, #2, #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9). The facility failed to: 1. Have an effective system in place to ensure Resident #R7 was adequately supervised to prevent her from exiting the building unsupervised on 06/25/2024 and 08/03/2024; 2. Complete an incident report and/or thoroughly investigate Resident #R7's elopements on 06/25/2024 and 08/03/2024; and 3. […]

• Actual harm, isolatedF600Aug 19, 2024

  Based on interview and record review, the facility failed to ensure a resident's right to be free from verbal and mental abuse by staff for 1 (Resident #1) of 12 (Resident #1, Resident #2, Resident #3, #R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, and #R9) sampled residents. This failed practice resulted in an actual harm situation for Resident #1 on 07/23/2024 on the 6:00 p.m. to 6:00 a.m. shift when Resident #1, who was severely impaired cognitively, and had diagnoses of Dementia and Major Depressive Disorder, was verbally and mentally abused by S3 CNA. Review of Resident #1's video camera footage revealed on 07/23/2024 at 7:54 p.m., S3 CNA while in Resident #1's room stated to Resident #1 You old meanie. […]

• No harm, potential for more than minimal, widespreadF882Jun 17, 2026

  Based on record review and interviews, the facility failed to designate an individual as Infection Preventionist who was responsible for the facility's infection prevention and control program who has completed specialized training in infection prevention and control. Findings:In an interview on 06/17/2026 at 12:45 p.m., S7 RN TX revealed she oversees the Infection Prevention and Control Program. S7 RN TX confirmed she does not have the Infection Preventionist training.In an interview on 06/17/2026 at 2:51 p.m., S2 DON confirmed S7 RN TX oversees the Infection Prevention and Control Program and does not have the Infection Preventionist training but should have.

• No harm, potential for more than minimal, widespreadF880Apr 16, 2024

  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 infections. The facility failed to: 1. Implement Enhanced Barrier Precautions (EBP) for residents whom EBP are indicated. 2. Maintain a water management program, to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the facility's water system. This deficient practice had the potential to affect all residents who reside in the facility. The total resident census was 76. Findings: 1. Observation on 04/14/2024 at 1:20p.m. […]