Angel Oak Nursing and Rehabilitation Center, LLC

In the surveyor’s words

From the most serious findings on record at Angel Oak Nursing and Rehabilitation Center, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 7, 2026

  Based on interview, record review, and facility policy review, the facility failed to provide adequate supervision and accident prevention for 1 (Resident (R)65) of 3 residents reviewed for falls. The failure resulted in R65 sustaining a right 11th rib fracture on 09/02/2025 after the resident fell. Findings include: Review of a facility policy titled, Accidents and Supervision, revised on 10/06/2025, revealed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. […]

• Actual harm, isolatedF600Mar 21, 2023

  Based on review of the facility's policy, record review, video surveillance review and interviews, the facility failed to protect Resident (R)4 from physical abuse by R5, 2 of 8 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation last revised 9/22, revealed It is policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. […]

• No harm, potential for more than minimal, widespreadF812Oct 19, 2022

  Based on review of the facility policy, observations, and interviews, the facility failed to provide food storage in a safe manner in 1 of 1 main kitchen. This had the potential to affect all residents who consume food from the kitchen. Findings Include: Review of the facility policy titled, Date Marking for Food Safety with an implementation date of March 2022, revealed Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Complaisance for Staffing: 6. […]

• No harm, potential for more than minimal, widespreadF880Jan 14, 2021

  Based on observations, interviews, and record review, the facility failed to implement an Infection Prevention and Control Program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the spread of the Coronavirus (COVID-19) and other infections. Specifically, the facility failed to: 1. Ensure multi-use vital sign equipment (blood pressure curve and pulsed oximeter) was disinfected between residents' use for four of four residents (Rooms #217, #218, #220, and #222) observed; and 2. […]

• No harm, potential for more than minimal, patternF558Oct 19, 2022

  Based on review of the facility policy, observations, record reviews, and interviews, the facility failed to ensure 4 of 8 residents, (Resident (R)13, R68, R53, and R73), had their call light within reach. Findings Include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response dated August 2022, revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside . to allow residents to call for assistance. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on . ensuring resident access to call light. 5. […]