Lady of the Oaks Retirement Manor

In the surveyor’s words

From the most serious findings on record at Lady of the Oaks Retirement Manor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Sep 26, 2023

  Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the spread of Coronavirus Disease-2019 (COVID-19) as evidenced by staff not putting on the required Personal Protective Equipment (PPE) before entering isolation rooms. This deficient practice had the potential to affect a census of 100 residents. Findings: Review of the facility's policy titled Isolation Policy and Procedure read in part .4. Droplet Precautions: b. Gloves, gown, mask, and goggles are to be utilized for all interactions that may involve contact with the resident. Resident #3 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection and Other Abnormalities of Breathing. […]

• No harm, potential for more than minimal, patternF677May 19, 2026

  Based on observations, interviews and record reviews, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 (#3, #86, #91, #104) of 4 (#3, #86, #91, and #104) residents reviewed for ADLs. Findings: On 05/19/2026, a review of the facility's policy titled AM Care Policy and Procedure with a last reviewed date of 09/05/2025, read in part: Policy: AM care will be provided to all residents daily and as needed. Procedure.7. Shave resident if applicable.12. […]

• No harm, potential for more than minimal, patternF812May 19, 2026

  Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service as evidenced by:1. S8DA failing to cover exposed facial hair while serving food to residents,2. Food items in the facility's kitchen cooler and freezer were unlabeled, opened, and undated;3. lack of cleanliness of the facility's kitchen;4. Failing to ensure kitchen equipment was in good repair; and5. Failing to ensure foods on the food service line were at appropriate temperatures.This deficient practice had the potential to affect the 102 residents who consumed foods from the kitchen.Findings:1. Review of the facility's policy titled, Employee Sanitation Practices with a last reviewed date of 09/05/2025, revealed in part .3. […]

• No harm, potential for more than minimal, patternF880May 19, 2026

  Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. This was evidenced by:A dirty trash can on Resident #115's bed.Staff failing to perform appropriate hand hygiene during medication administration; andStaff failing to follow enhanced barrier precautions (EBP) for Resident #33 and Resident #78.Findings: 1. On 05/17/2026 at 10:49 a.m., an observation was made of Resident #115's room. The resident was not in her room. There was a yellow wet floor sign at the entrance to the room. […]

• No harm, potential for more than minimal, patternF656Jun 3, 2025

  Based on records reviewed, observations, and interviews, the facility failed to ensure the resident's care plan and physician's orders were followed for 3 (#11, #91, and #102) of 34 sampled residents. This was evidenced when: 1. Facility staff failed to administer Resident #11, and Resident #102 their therapeutic diets as prescribed by the physician. 2. Facility failed to maintain right and left ear cushions to nasal cannula for Resident #91 3. Facility staff failed to ensure Resident #102 was assisted in meal set up per her comprehensive care plan, and failed to administer oxygen according to physician orders. […]