Oak Knoll Health and Rehabilitation, LLC

In the surveyor’s words

From the most serious findings on record at Oak Knoll Health and Rehabilitation, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584May 19, 2023

  Based on observations, interviews, record reviews, review of a facility policy titled, Resident Environmental Quality, a facility policy document titled, Resident Rights, a facility document used for weekly testing of fire door exits, and the State Agency's Online Incident Reporting System Report, the facility failed to ensure residents were safe and their property was protected by failing to provide a safe environment. The facility failed to repair a broken, unsecured door in the facility, allowing anyone to gain access to the facility, unauthorized and without staff knowledge. Also, the facility failed to ensure unauthorized person (i.e., former employees) did not have the active door entry code to gain access to resident care areas. […]

• Immediate jeopardy, widespreadF835May 19, 2023

  Based on observations, interviews, review of the Administrator's Job Description, facility policies titled, Resident Environmental Quality and Resident Rights, and the State Agency's Online Incident Reporting System Report, the facility administrator, who was responsible for day-to-day operations, failed to ensure the physical environment of the facility was safe and secure for residents' and staffs' safety. The Administrator, Employee Identifier (EI) #1, admitted to knowing an exterior door, leading to the inside of facility, needed to be repaired for approximately one year before the facility was robbed of residents' narcotic medications and an employee cellular phone on 05/04/2023. […]

• No harm, potential for more than minimal, widespreadF812Mar 18, 2021

  Based on observations, record review, interviews and review of facility policy, the facility failed to store, prepare, and distribute food in a sanitary manner for two (2) of three (3) days of the survey. This deficient practice has the ability to affect all residents that received food or beverage from the facility's kitchen. Findings include: Interview with the Dietary Cook on 3/16/21 at 10:00 a.m. revealed the Certified Dietary Manager (CDM) was not in the facility at this time. Observation during the initial tour of the kitchen on 3/16/21 from 10:00 a.m. to 10:30 a.m. […]

• No harm, potential for more than minimal, patternF803Mar 18, 2021

  Based on observation, record review, interview and review of facility policy, the facility failed to follow the menus. Specifically, the facility failed to follow the recipes for the pureed menu items, failed to follow the menu for pureed corn bread, and failed to adhere to the appropriate serving size of the bread for 12 of 12 residents that received pureed diets (Resident #5, Resident #6, Resident #22, Resident #23, Resident #25, Resident #27, Resident #30, Resident #31, Resident #36, Resident #78, Resident #139, and Resident #140). Findings include: Interview on 3/17/21 at 10:55 a.m. revealed the Dietary Cook stated he/she would make 16 servings of the pureed menu items. […]

• No harm, potential for more than minimal, isolatedF600May 2, 2024

  Based on record review, interview, review of an Online Incident Report and review of facility policy Abuse, Neglect Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure Resident Identifier RI #1 was not talked to in a demeaning way by a Certified Nursing Assistant (CNA) #4. This incident occurred on 1/28/24 and affected RI #1. This was cited as a result of investigation of complaint/report number AL00046804 and affected RI #1, one of one resident verbally abused. Findings include: Review of a facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of 10/15/2022 documented . […]