Green Oaks Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Green Oaks Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF760Jan 20, 2024

  Based on, interview and record review, the facility failed to ensure that residents are free of any significant medication errors for 1 (Resident #1) of 11 residents reviewed for significant medication error. The facility staff failed to verify Resident #1's allergy to penicillin before administering antibiotic containing penicillin from [DATE] to [DATE]. The facility staff failed to recognize or check to ensure the antibiotic Resident #1 was receiving did not have penicillin in it when some staff knew the resident was allergic to penicillin. Resident #1 expired on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:15 pm. […]

• Actual harm, isolatedF689Mar 7, 2023

  Based on interviews, observations, and record reviews the facility failed to ensure that residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for falls. On 02/24/23 CNA A failed to ensure she had assistance while providing care to Resident #1, who was care planned to have the assistance of two-persons for ADL care. This resulted in Resident #1 falling from bed on 02/24/23 and sustaining a right arm fracture and fracture of the right great toe. This failure placed the residents at risk for injury. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2025

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure the standby refrigerator temperature measured at 41F or less. 2. The facility failed to ensure walk-in refrigerator food items were dated and labeled. 3. The facility failed to ensure dry storage food items were dated, labeled, and stored securely. 4. The facility failed to ensure canned goods were free of dents. 5. […]

• No harm, potential for more than minimal, widespreadF880Jan 13, 2025

  48520 Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 Residents (Resident #82) observed for infection control and 4 of 4 quarters reviewed for water management. 1. The facility staff failed to use proper technique when flushing Resident #82's IV while the resident was on enhanced barrier precautions. 2. The facility failed to implement a water management program per facility policy. These failures could place residents at risk of cross-contamination and infections. Findings included: 1. […]

• No harm, potential for more than minimal, patternF628Aug 12, 2026

  Based on interview and record review, the facility failed to provide written notice of the facility's bed-hold policy to 3 of 3 residents (Residents #1, #2, #3) and/or the resident representative at the time the resident was transferred to the hospital. The facility failed to provide Residents #1, #2, and #3 and/ or the resident representative with written information specifying the duration of the state bed-hold period, the facility's bed hold policies, and the resident rights to return to the facility as required. This failure placed residents at risk of being unaware of the facility's bed-hold policy, including the resident's right's regarding holding the resident's bed and returning to the facility following hospitalization. […]