Oakhurst Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Oakhurst Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 29, 2025

  Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the resident's right to be free from neglect by failure to provide timely identification and management of a pressure wound for one resident, Resident #4 (R4) in a survey sample of six residents, which deprived the resident of needed care to avoid physical harm of severe wound deterioration. by facility staff with regards to identification and treatment of a pressure ulcer until it was at an advanced stage and neglected to implement and treat a pressure ulcer for one resident, Resident #4 (R4) in a survey sample of six residents which resulted in harm for R4. […]

• Actual harm, isolatedF686Apr 29, 2025

  Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to identify a pressure ulcer until it was at an advanced stage, implement and treat a pressure ulcer for one resident, Resident #4 (R4) in a survey sample of six residents which resulted in harm for R4. The findings included: For Resident #4 (R4), the facility staff discovered an in-house acquired pressure wound, which was at an advanced stage upon discovery, as evidenced by having greater than 70% slough (dead tissue). Upon identification, the facility staff initiated a one-time treatment without a physician order and failed to obtain treatment orders for ongoing treatment of the wound. […]

• Actual harm, isolatedF689Oct 6, 2021

  Based on observation, staff interview, and clinical record review, the facility staff failed to provide adequate supervision and/or services to prevent accidents for 2 of 18 residents in the survey sample, Resident #48 and Resident #11. Resident #48 was not provided adequate monitoring/supervision, sustained an injury of unknown origin on his head that required 5 staples, resulting in harm. Resident #11 was not provided fall mats as required in her care plan. The findings include: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses that included infarction, [CONDITION(S)] and [CONDITION(S)] affecting right dominant side, muscle weakness, dementia with behavioral disturbance, [CONDITION(S)], anxiety, hypertension, depression, dysphasia and [CONDITION(S)]. […]

• No harm, potential for more than minimal, widespreadF887Feb 22, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season, to 5 of 5 residents (Resident #6, 31, 3, 55, and 14) and 5 of 5 staff (RN #3, CNA #6, Other Employee #1, Other Employee #5, and Other Employee #7) sampled. The findings included: 1. For five residents (R6, R31, R3, R55 and R14), the facility staff failed to provide education and offer the COVID-19 spike vaccine booster for the 2023-2024 season. On 2/20/24 and 2/21/24, clinical record reviews were conducted of R6, R31, R3, R55 and R14's charts. This review revealed no evidence that any of the sampled residents had been offered the COVID-19 spike vaccine. […]

• No harm, potential for more than minimal, patternF580Jul 2, 2026

  Based on staff interview, clinical record review, and facility document review, the facility staff failed to notify the physician or responsible party of a change in condition and/or need to alter treatment for two of seven residents, Residents #1 and #2. The findings include: 1. For Resident #1 (R1) the facility staff failed to notify the responsible party of change in condition. R1 diagnoses include but were not limited to Alzheimer's disease (1), aphasia (2) dysphagia (3), and protein-calorie malnutrition (4). On the most recent minimum data set (MDS), nursing home discharge of 6/6/2026, the resident's BIMS (brief interview for mental status) score was not entered. […]