Hebron Oaks

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Feb 18, 2025

  Based on observation, interview, and record review, the facility did not ensure each resident receives cares, consistent with professional standards of practice to promote healing, prevent infection, and prevent new injuries from developing for 2 of 3 residents (R1 & R3) reviewed with pressure injuries or at risk for developing pressure injuries. R1 was admitted on [DATE], without a pressure injury. R1 developed three pressure injuries - two identified as Deep Tissue Injuries (DTIs; a type of pressure injury that occurs when prolonged pressure or shear forces damage the underlying soft tissues, such as muscle, fat, and tendons) and one Unstageable (a full thickness wound where the base of the injury is obscured by a layer of dead tissue called slough or eschar). […]

• Actual harm, isolatedF689Oct 27, 2022

  Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed for fall concerns. R1 had a care plan intervention for anti-rollbacks to the wheelchair. R1's wheelchair did not have the anti-rollbacks in place and R1 fell out of the wheelchair and fractured his left ankle. Evidenced by: The facility's Fall Prevention Program policy dated 3/23/22 states in part: .Due to this fragile population, all residents will be considered at risk for fall . 2. Evaluation, care planning and monitoring of residents related to fall issues will be initiated by the primary nursing staff along with input from Fall Team Meetings, observation and/or staff report. 3. […]

• No harm, potential for more than minimal, widespreadF812Jul 17, 2025

  Based on observation, interview, and record review, the facility did not ensure food was stored, prepared, and served in a safe and sanitary manner. This practice has the potential to affect all 42 residents who reside at the facility. Surveyor observed left over food items not properly covered, labeled, and expired. Surveyor observed walk in freezer to have a large puddle of water outside freezer, door sticking, and to the front left side of the freezer large chunks of ice covering boxes of food and left over food item. Surveyor observed cleanliness concerns in main kitchen. Surveyor observed staff in kitchen and kitchenette not wearing beard restraints.Surveyor observed staff wearing gloves, touching cabinets and door handles, and then directly touching food with same pair of gloves. […]

• No harm, potential for more than minimal, widespreadF730Feb 18, 2025

  Based on record review and staff interviews, the facility did not complete a performance review of every nurse aide at least every 12 months for 5 of 5 Certified Nursing Assistants (CNAs) reviewed for in-service training. The survey team randomly selected five (5) facility CNAs who have been employed at the facility for longer than one (1) year. CNA/MT O (Certified Nursing Assistant/Medication Technician), CNA/MT P (Certified Nursing Assistant/Medication Technician), CNA Q (Certified Nursing Assistant), CNA R (Certified Nursing Assistant), and CNA S (Certified Nursing Assistant) did not have a performance review at least every 12 months. […]

• No harm, potential for more than minimal, widespreadF812Mar 9, 2023

  Based on observation, interview and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 32 residents. Hood vents with visible clumps of dust. Kitchen staff with facial hair were not wearing beard restraints. Findings include Example 1 On 3/7/23 at 10:32 AM, Surveyor observed hood vents with visible clumps of dust in the main kitchen. The dust appeared to be separating from the hood vents. These hood vents were directly above a large [NAME] of soup that was uncovered and actively being prepared and mixed by facility staff. EC C (Executive Chef) stated to Surveyor at this time that the hood vents were dirty and needed to be cleaned. […]