Delta Oaks Post Acute

In the surveyor’s words

From the most serious findings on record at Delta Oaks Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 15, 2026

  Based on interview and record review, the facility failed to implement safety measures to prevent accidents for one of three sampled residents (Resident 1) when on 3/31/26 while Certified Nursing Assistant (CNA) 1 was providing care alone to Resident 1 on a low air loss mattress (LAL -low air loss mattress, a specialized therapeutic surface featuring air-filled bladders with tiny holes that release a constant, gentle flow of air), Resident 1 fell off of the bed onto the concrete ground.This failure resulted in Resident 1 falling from an elevated bed (approximately 3 feet) onto the concrete ground which resulted in Resident 1 being sent to the emergency department with injuries that included, a fracture to Resident 1's cervical spine neck (C1 -a traumatic break of a bone at the top of the… […]

• Actual harm, isolatedF689Apr 8, 2025

  Based on interview, and record review, the facility failed to provide adequate supervision for one of five sampled residents (Resident 1) when Resident 1's physician order to monitor every 15 minutes for suicidal ideation (thinking about, considering, or being preoccupied with the idea of death and suicide) was not followed. This failure resulted in Resident 1 causing harm to himself by cutting his arms and legs multiple times with a razor blade on 8/8/24 and being admitted to an acute care hospital for treatment. […]

• Actual harm, isolatedF684Jul 17, 2024

  Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), received quality of care (health services for individuals and populations increase the likelihood of desired health outcomes) according to professional standards of practice (a set of principles, goals, and expectations that describe the rights and responsibilities of professionals in a specific practice) when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time to more easily visualize the veins for blood removal needed for testing) was left around Resident 1's right arm for approximately three days and the nursing staff did not perform a detailed skin assessment of Resident 1's skin. […]

• Actual harm, isolatedF600Aug 26, 2021

  Based on interview, clinical record review, and facility policy review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when staff failed to redirect Resident 2 before he slapped Resident 1 in the face. This failure resulted in redness and swelling to Resident 1's right eye and cheek, and had the potential to cause psychosocial harm to Resident 1. Findings: A clinical review of Resident 1's clinical record indicated the following documents: An Admission Record, indicated Resident 1 was admitted to the facility in November of 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Aug 19, 2026

  Based on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment and implement infection prevention and control practices (steps taken to prevent and stop the spread of infection) to minimize the potential for contamination and transmission of infectious agents (germs that can make a person sick) for a census of 104 when the facility failed to:1. Store clean linens in a manner that protected them from potential contamination when clean linens were placed directly on top of a trash receptacle in Resident 1's room;2. […]