Oakcrest Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Oakcrest Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jul 17, 2024

  Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 5 of 5 residents (Resident #43, Resident #47 , Resident #52, Resident #57, and Resident #67) reviewed for comprehensive care plans. These failures could place residents at risk of not having individual needs met, a decreased quality of life, causes residents not to receive needed services and death. 1. […]

• Immediate jeopardy, isolatedF689Jul 17, 2024

  Based on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #47) of 5 residents reviewed for accidents. The failed to ensure resident #47 was being monitored during meal intake resulting Resident #47 choking and ultimately passing away. This failure could result in other residents not getting the assistance or the supervision needed when they have swallowing difficulties and could also lead to severe injury and/or death. An IT was identified on [DATE] at 12:00 PM. The IT template was provided to the facility on [DATE] at 12:47 PM. […]

• Immediate jeopardy, isolatedF689Apr 10, 2024

  Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistant device to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accident hazards/supervision. Resident #1 walked out of the facility unattended on 04/01/24 at 8:08PM and remained missing as on 04/10/24 at 3:00PM. LVN B failed to physically check during the two-hour monitoring to ensure Resident #1 was in the building during and after his elopement. An IJ was identified on 04/03/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 6:00PM. […]

• Immediate jeopardy, isolatedF689Dec 3, 2022

  Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards, in that: The facility failed to: 1. Ensure the fence surrounding the facility was secured. 2. Ensure functioning door alarms were installed. 3. Follow Resident #1's care plan by physically checking on him every two hours. Resident #1 eloped from the facility on 11/09/22 and was found 14-16 hours later and five miles away on a high-trafficked highway. These deficient practices placed residents at risk for unsafe elopements, falls, injuries, and hospitalization . […]

• No harm, potential for more than minimal, widespreadF812Aug 7, 2025

  Based on interview, observation and record review the facility failed to maintain infection control practices during food preparation for 1 of 1 meal observed for meal preparation. The DS failed to maintain infection control practice by:1. The DS failed to complete hand hygiene appropriately.2. The DS failed to sanitize the thermometer with a clean alcohol swab between food items. 3. The DS failed to sanitize the thermometer after touching another surface with the thermometer. These failures could result in cross contamination or food allergies. Findings Include: An observation was conducted on 08/06/2025 at 11:25AM while the DS pureed the food for lunch. The DS had placed the chicken into the puree blender and completed the puree process. […]