Country Oaks Care Center

In the surveyor’s words

From the most serious findings on record at Country Oaks Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF740Apr 27, 2023

  Based on observation, interview, and record review, the facility failed to provide one of four sampled residents (Resident 1) with behavioral health care and services for the treatment of Resident 1's emotional, mental, and drug abuse (a disease that affects a person's brain and behavior and leads to an inability to control the use of a legal or illegal drug or medication) by failing to: 1. Identify goals and nursing interventions when Resident 1 had cannabis (marijuana, a mind-altering drug), sedative (a category of drugs that slow brain activity) abuse, anxiety (nervousness), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) would leave the facility on out on pass (OOP, temporary permission of a resident to leave the… […]

• No harm, potential for more than minimal, patternF580Aug 24, 2026

  Based on interview and record review, the facility failed to promptly notify two of three sampled residents' (Resident 3's and Resident 7's) representatives (RR), according to the facility's Policy and Procedure (P&P) titled, Notification of Changes, dated 12/19/2022, when:a. On 8/4/2026, the facility failed to notify RR 1 of Resident 3's fall that occurred in the shower.b. On 8/15/2026, the facility failed to notify RR 2 of Resident 7's fall that occurred in the shower.These failures had the potential for Resident 3's and Resident 7's representatives not being able to advocate for or assist Residents 3 and 7 in participating in decision making of treatment following their falls.(Cross reference F689 and F725)a. […]

• No harm, potential for more than minimal, patternF689Aug 24, 2026

  Based on interview and record review, the facility failed to provide care and services to prevent falls for three of four sampled residents (Residents 3, 7, and 9) when:a. The facility replaced wheels on a shower chair (a movable or rolling waterproof seat used by residents who cannot safely stand during showering) with wheels that were larger than the original set. As a result, Resident 3 fell from the shower chair when the shower chair tipped while Certified Nursing Assistant (CNA) 1 was showering Resident 3.b. CNA 2 failed to ensure Resident 7's shower chair was locked in place according to the facility's Policy and Procedure (P&P) titled, Resident Showers, dated [DATE], when providing a shower to Resident 7. […]

• No harm, potential for more than minimal, patternF725Aug 24, 2026

  Based on interview and record review, the facility failed to provide sufficient number of certified nursing assistants (CNAs) on [DATE] and [DATE] according to the facility's Facility Assessment Tool (FAT - facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies), updated [DATE]. The facility also failed to save CNA staffing assignments from [DATE] and [DATE].This failure had the potential to result in residents receiving inadequate care and supervision which can lead to falls, elopement, and delayed recognition of residents' significant changes in condition. […]

• No harm, potential for more than minimal, patternF732Aug 24, 2026

  Based on observation, interview, and record review, the facility failed to post actual nursing hours worked at the start of each shift according to the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, revised 3/10/2025.This failure had the potential to result inaccurately reflecting the actual nurses providing direct care to the residents.During a concurrent interview and record review on 8/24/2026 at 1:37 PM with the Director of Staff Development (DSD), the facility's Nurse Staff Projection (NSP), dated 8/20/2026, was reviewed. […]