Oak Village

In the surveyor’s words

From the most serious findings on record at Oak Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF656Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement resident's plan of care based on current status for 1 of 1 resident reviewed for pressure ulcers, 3 of 5 residents reviewed for accidents, and 1 of 5 residents reviewed for unnecessary medications. A resident lacked a care plan for a current stage 3 pressure ulcer, lacked a care plan for behavior of cannabis smoking, lacked a care plan for antiplatelet medication, and not following fall interventions. (Resident 28, Resident 9, Resident 1, Resident 30, Resident 5)Findings include:1. During an observation on 12/18/25 at 10:48 A.M., Resident 5 was observed in the common area by the nurses' station in his wheelchair. […]

• No harm, potential for more than minimal, patternF657Dec 22, 2025

  Based on interview and record review, the facility failed to ensure resident care plans were revised to reflect current status for 1 of 1 residents reviewed for pressure ulcers and 3 of 5 residents reviewed for unnecessary medications. A resident's pressure ulcer care plan had not been discontinued when the area healed, resident's care plans reflected current use of a discontinued medications, a fall care plan was not revised to include current interventions, and a current diagnosis of shingles and pneumonia that were no longer active (Resident 28, Resident 4, Resident 30, Resident 1)Findings include:1. On 12/21/25 at 9:12 P.M., Resident 1's clinical record was reviewed. Diagnoses included, but were not limited to, diabetes mellitus type II, anxiety, and peripheral vascular disease. […]

• No harm, potential for more than minimal, patternF880Dec 22, 2025

  Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and comfortable environment for all residents for 3 of 3 random observations. The resident's oxygen tubing was dragging on the ground, the urinary catheter bag and tubing were dragging on the floor, and clean linens were carried against a staff member's uniform shirt. (Resident 4, Laundry 9, Resident 23)Findings include: 1. On 12/11/25 at 11:57 A.M., Resident 23 was observed propelling himself in his wheelchair down the hallway with a urinary catheter tube dragging under the resident's black shoe and hitting the floor at times. […]

• No harm, potential for more than minimal, patternF812May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety during 1 of 1 kitchen observations and failed to complete hand hygiene during meal service. Food was stored in a reach in freezer in the kitchen open to air, undated, and unlabeled. The kitchen equipment and spaces contained dust and debris, and the staff failed to complete hand hygiene after coming in contact with residents while assisting in the dining room. (Resident D, Resident F, Resident G) Findings include: 1. […]

• No harm, potential for more than minimal, patternF804Dec 31, 2024

  Based on observation, interview, and record review, the facility failed to provide appetizing and palatable meals for 1 of 1 lunch trays sampled on 1 of 2 halls. Residents complained of cold food temperatures and unappetizing food during meals. (100 hall, Resident J, Resident M, Resident P) Finding includes: During an interview on 12/30/24 at 10:40 A.M., Resident J indicated that she disliked the food at the facility. During an interview on 12/30/24 at 10:55 A.M., Resident M indicated at 1:00 P.M., Resident M indicated that the hot food was often served cold. During a review of facility Resident Council minutes on 12/30/24 at 11:10 A.M., a concern was reported to the facility, dated 12/27/24, that the hot food was cold and colder than last month. […]