Oak Knoll Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Jun 12, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing) with several episodes of choking which required nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), the Facility failed to ensure his/her Dysphagia Care Plan was reviewed and/or revised related to effectiveness of interventions, when he/she remained on the same diet but continued to experience choking episodes and despite recommendations from Speech Therapy to implement a new intervention for direct supervision by staff during all meals, he/she was only supervised from a distance… […]

• Immediate jeopardy, isolatedF689Jun 12, 2025

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had a history of dysphagia (difficulty swallowing), was identified to be at increased risk for aspiration, with multiple choking episodes which required the nursing staff to perform the Heimlich Maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which sudden strong pressure is applied on the abdomen, between the navel and the rib cage), and for whom Speech Therapy had recommended the need for direct supervision by nursing staff while eating, the Facility failed to ensure they provided an adequate level of staff supervision for Resident #1 in an effort to maintain a safe environment, when on 5/02/25, he/she choked again on his/her meal, and although nursing… […]

• No harm, potential for more than minimal, widespreadF867Jan 3, 2022

  Based on record review and interview, the facility failed to develop and implement plans of action quarterly, as required, to correct identified quality deficiencies for three of four quarters in 2021. Findings include: During an interview on 1/03/22 at 8:49 A.M., the Administrator said that Quality Assurance Performance Improvement (QAPI) meetings were held quarterly. The Administrator provided a current QAPI plan dated December 2021 to address vaccine boosters and falls, but was unable to provide any other QAPI plans developed throughout 2021. […]

• No harm, potential for more than minimal, patternF812Aug 28, 2023

  Based on observation and interview, the facility failed to maintain professional standards relative to food storage and sanitation in one of three nourishment kitchens. Findings include: Review of the facility's Nourishment policy dated January 2016, indicated the following: -Dietary is responsible for monitoring and recording the temperatures of both the refrigerator and freezer of the nourishment refrigerators. -All non-nourishment food will be discarded immediately Review of the 2022 United States Food and Drug Administration Food Code indicated the following: *Food shall be protected from contamination by storing the food: -In a clean, dry location. -Where it is not exposed to splash, dust, or other contamination. -At least 15 centimeters (six inches) above the floor. […]

• No harm, potential for more than minimal, patternF880Aug 28, 2023

  Based on observations, policy reviews and interviews, the facility failed to adhere to Infection Control policies/practices during a COVID-19 outbreak. Specifically the facility staff failed to: 1) utilize the appropriate precaution signs on one out of three units during an outbreak of COVID-19 infection. 2) use appropriate personal protective equipment (PPE) by staff in a manner that would minimize the spread of COVID-19 infection during an active outbreak for one Resident (#96) out of four applicable residents, out of a sample of 21 residents. 3) to ensure staff were tested for COVID-19 as required when the facility was experiencing an outbreak of COVID-19 infections. […]