English Oaks Convalescent & Rehabilitation Hospita

In the surveyor’s words

From the most serious findings on record at English Oaks Convalescent & Rehabilitation Hospita, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 31, 2025

  Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to implement two persons assist when mechanical lift (a medical device used to safely lift and move a resident) was used to transfer (moving from one place to another) Resident 1.These deficient practices led to Resident 1 sustaining a fall that resulted in intramuscular hematoma (collection of blood within a muscle) to the right pectoralis (chest muscle) and a broken right leg.Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction, (a condition where blood flow to the brain is… […]

• No harm, potential for more than minimal, widespreadF802Jan 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure the kitchen staff carried out proper dress code when dietary relief (DR) 1 did not wear a beard net properly exposing facial hair. This failure had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen. The facility census was 167.Findings: During a concurrent observation and interview on 1/14/26, at 11:15 a.m., with registered dietitian (RD) 1, tray line (assembly line for food, commonly used in hospitals and nursing homes to prepare patient meals. Workers stand at stations, adding specific items-like hot food, drinks, or cutlery-to a moving tray as it passes) was observed. […]

• No harm, potential for more than minimal, widespreadF812Sep 20, 2024

  Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1) Three serving scoops were dirty with green and brown crusted substances, and were stored with clean serving utensils in a cook's undercounter drawer; 2) Eleven cases of thawed, soft mighty healthshakes were stored in the walk-in refrigerator and two cases of them were received on [DATE]; 3) A pipe from the dish machine did not have an air gap; and, 4) Two ice machines were not cleaned and maintained according to manufacturer's instructions. […]

• No harm, potential for more than minimal, patternF732Aug 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing information accurately and completely reflected the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift when the facility's daily nurse staffing posting did not reflect the actual hours worked per shift by nursing staff responsible for resident care.This deficient practice had the potential to prevent residents, staff, visitors, and the public from having access to complete, accurate, and current nurse staffing information for a facility census of 165 residents. […]

• No harm, potential for more than minimal, patternF755Jan 16, 2026

  The facility failed to ensure safe pharmaceutical services with medication disposal, waste, and the accountability of delivered medications based on standards of practice for a resident census of 167 when: 1. Pharmaceutical waste (discontinued or no longer needed drugs) including prescription and over the counter (drugs sold directly to consumers without needing a prescription) medications were not rendered unusable when disposed in the pharmaceutical waste bin (also known as a drug waste bucket) and were accessible with hand retrieval from the waste bin; and, 2. Medication delivery slips and manifests from the pharmacy provider were not consistently signed and dated by licensed staff upon receipt from delivery courier for accuracy and accountability of prescription medication received. […]