Oak Haven Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Apr 16, 2026

  Based on observation, interview and record review, The facility failed to ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision; and failed to ensure the resident's (#61) environment remained as free of accident hazards as possible for 1 (#61) of 5 sampled residents reviewed for elopement risk. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the building unsupervised. […]

• Immediate jeopardy, patternF726Apr 16, 2026

  Based on observation and interview, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#61) of 5 sampled residents reviewed for elopement. The facility failed to ensure staff were knowledgeable and able to identify residents at risk for elopement. This deficient practice resulted in an Immediate Jeopardy situation on 03/26/2026 at approximately 7:50 p.m., when S3CNA who failed to recognize Resident #61 as an elopement risk, unlocked a facility door, and allowed Resident #61, who had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard, to exit the… […]

• Immediate jeopardy, patternF835Apr 16, 2026

  Based on observation, record review, and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (Resident #61) of 5 sampled residents reviewed for elopement. The facility failed to:1. Ensure a cognitively impaired resident (#61) who was identified as being at high risk for elopement, wandering and exhibited exit seeking behaviors did not exit the building without supervision;2. Ensure staff were knowledgeable and able to identify residents at risk for elopement;3. Implement appropriate interventions and/or increase supervision after identifying the wanderguard security system was not functioning properly; and4. […]

• Immediate jeopardy, isolatedF678Mar 21, 2024

  Based on interview and record review facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders, and the resident's advance directives for 1 (Resident #76) of 2 (Resident #76 and Resident #77) closed records reviewed out of a total sample of 23. The facility failed to: 1. Ensure S4 LPN acted in accordance with Resident #76's Advanced Directives and Physician Orders, and initiated CPR when the resident was found unresponsive and without a pulse; and 2. Ensure EMS and the physician were notified when Resident #76 was found unresponsive, without a pulse. […]

• Actual harm, isolatedF689Dec 5, 2024

  Based on observation, interview and record review, the facility failed to provide adequate supervision, and use extensive, 2 person physical assistance for turning, repositioning and bed mobility for 1 (#1) of 2 (#1 and #2) residents reviewed for falls. This failed practice resulted in an actual harm situation on 11/07/2024 at 9:35 a.m., when Resident #1, who was severely impaired cognitively; had diagnoses that included Hemiplegia, and Hemiparesis following Cerebral Infarction affecting the Right Dominant Side; Unspecified Dementia; and required substantial/ maximal assistance for shower/ bathing and rolling left and right; rolled out of bed while receiving a bed bath by S4 CNA. Resident #1 fell on to the floor, and sustained a Closed Right Hip Fracture. […]