Oak Haven Rehab and Nursing Center

In the surveyor’s words

From the most serious findings on record at Oak Haven Rehab and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 26, 2022

  Based on observations, interviews and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen related to not labeling or dating foods, not maintaining refrigerator and freezer temperature logs, not implementing cleaning schedules and not utilizing sanitizing buckets for three days (5/23/22, 5/24/22 and 5/25/22) of four days observed. Findings included: On 05/23/2022 at 9:26 a.m., the initial kitchen tour was conducted with Staff J, Cook Manager. An observation of the walk-in cooler revealed no thermometer found inside the cooler. […]

• No harm, potential for more than minimal, patternF842Apr 12, 2026

  Based on observations, record reviews, and interviews the facility failed to ensure skilled documentation for two (#1 and #7) of three residents sampled was completed daily, failed to ensure a change in condition and transfer evaluation was conducted for one (#1) of one sampled resident prior to transferring to an acute care facility, and failed to ensure one (#6) of one resident medical record contained documentation related to the dislodgement of an indwelling urinary catheter. Findings included: 1.An observation and interview were conducted on 4/12/26 at 9:20 a.m. with Resident #7 and spouse. The spouse reported wanting the resident to lay down after therapy but has not informed anyone of the wishes, will do so on Monday (next day). […]

• No harm, potential for more than minimal, patternF865Apr 12, 2026

  Based on record reviews and interviews the facility failed to maintain an effective, comprehensive Quality Assurance and Performance Improvement program (QAPI) related to the development and implementation of corrective actions or performance improvement activities as evidence by the continued absence of daily skilled assessments for residents receiving skilled services.Findings included:Review of Resident #7's admission Record showed the resident was admitted on [DATE]. The record included diagnoses not limited to paroxysmal atrial fibrillation, hypertensive heart disease without heart failure, generalized muscle weakness, adult failure to thrive, and Encounter for surgical aftercare following surgery on the circulatory system.Review of Resident #7's active physician orders revealed the… […]

• No harm, potential for more than minimal, patternF842Jul 28, 2025

  Based on interview and record review the facility failed to ensure the medical record was complete related to Activities of Daily Living (ADLs) for 3 of 3 sampled residents (#1, #2, #3)Findings included: 1. Resident #2 was admitted on [DATE]. Review of the admission Record showed diagnoses included but not limited to Parkinson’s, dementia, anemia, and hypotension. Review of the Minimum Data Set (MDS) dated [DATE] showed Section GG, Functional Abilities dependent for toileting hygiene, showering and bathing, upper and lower body dressing. Review of the care plans showed the resident had an ADL self-care deficit related to chronic medical conditions. ADL needs and participation vary as of 07/18/2022. […]

• No harm, potential for more than minimal, patternF684Jul 18, 2024

  Based on observation, interview and record review the facility failed to ensure the weekly skin assessments were performed for 8 of 39 sampled residents (#19, #362, #90, #58, #8, #267, #5). The facility also failed to ensure wound care assessments were performed for 2 of 2 sampled residents of 14 non-pressure wounds (#90, #267). Findings included: 1. On 07/15/2024 at 4:30 p.m. Resident #19 was observed sitting in her wheelchair at bedside. She was dressed and groomed for the day. She stated she went out to breakfast with her son. Her oxygen via nasal cannula was in place and at 2 liters per minute. Resident #19 stated that the staff cares for her. They answer the call lights and give her showers. She stated she had been to the hospital a couple of times for breathing problems. […]