Five Oaks Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 5, 2025

  Based on record review, observation, staff interview, Nurse Practitioner and Medical Director interview, the facility failed to ensure the necessary supervision was provided to a cognitively impaired resident to prevent an avoidable accident. On 06/25/24 Resident #79, who was known to have poor safety awareness, returned from an outing on the facility's transportation bus and was left unattended on the bus by three staff members. The front door of the bus was left open. Resident #79 unbuckled her seatbelt and ambulated to the front of the bus exiting at the front stairs. The resident was wearing slip on shoes that came off, the resident lost her footing and experienced a fall from the bus steps, hitting her head and landing on her right side on the asphalt. […]

• Immediate jeopardy, isolatedF689May 16, 2023

  Based on record reviews and family, resident, physician, physical therapist, and staff interviews, the facility failed to ensure a safe transfer for 1 of 3 residents reviewed for accidents (Resident #8). An agency nurse aide (NA #1) transferred Resident #8 without the use of a mechanical lift from the bed to the wheelchair. NA #1 lifted Resident #8 under his arms and the Resident's left lower leg made contact with the side rail during the transfer. Resident #8 reported pain which worsened as a 10 centimeter (cm) by 6 cm hematoma (a collection of blood under the surface of the skin) developed rapidly on his left lower leg between the knee and the ankle. He was prescribed two medications that can cause bleeding prior to the incident. […]

• Immediate jeopardy, isolatedF689Feb 2, 2023

  Based on interviews with staff, Medical Director, Mental Health Nurse Practitioner (NP) and record review, the facility failed to provide close supervision of Resident #1 who was assessed as confused, impulsive, unsafe, with a history of falls and at risk for further falls. The facility failed to observe the condition of Resident #1 after an unwitnessed fall, report the observation to a nurse with any urgency, provide continuous monitoring after Resident #1 was found with his neck entrapped by a bed control cord and observed that his face was blue. Resident #1 was found on [DATE] after 7:00 PM by Nurse Aide (NA) #3 prone with his feet on the floor, but she did not enter the room to see his condition. Nurse #1 entered the room and found Resident #1 with his right side against his bed. […]

• Immediate jeopardy, isolatedF689May 16, 2022

  Based on record review, observations and interview with staff, Medical Director and the Nurse Practitioner the facility failed to increase supervision of Resident #57, knowing he had a history of removing his wanderguard (a device that triggers alarms and can lock monitored doors to prevent a resident from leaving unattended) device and failed to monitor the placement of Resident #57's wanderguard. On 3/17/22, he exited the facility without staff's knowledge and was found at the end of the parking lot near the road. Resident #57 was lying on the ground with his wheelchair behind him. He was not injured. 1 of 2 residents were reviewed for wandering behaviors (Resident #57). Immediate jeopardy began 3/17/22 when Resident #57 exited the facility unsupervised and sustained an unwitnessed fall. […]

• Actual harm, isolatedF686Mar 5, 2025

  Based on observations, record review, staff, Medical Director, and Wound Care Physician interviews, the facility failed to recognize a developing pressure ulcer, implement preventative measures, provided treatments as ordered, and consistently measure a resident's wounds on a weekly basis. The facility failed to have a Wound Care Provider evaluate residents at the facility when the Wound Care Physician was on vacation for 1 of 3 residents (Resident #59) reviewed for facility acquired pressure ulcers. On 11/20/24 Resident #59 developed discoloration to the coccyx area which developed to unstageable pressure ulcer on 12/06/24 that required a debriding agent (removal of dead tissue). […]