Oakridge Manor Nursing and Rehabilitation Center L

In the surveyor’s words

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

• Actual harm, isolatedF686Jul 22, 2026

  Based on observation, interview and record review the facility failed to ensure a resident did not sustain a facility acquired pressure ulcer and ensure continued treatment to the wound for one (R7) out of two reviewed for pressure ulcers resulting in a stage 4 pressure ulcer behind the left ear. Findings include: Upon entrance to the facility a facility matrix was provided to the Surveyors that noted R7 had a facility acquired pressure ulcers.On 7/20/26 at approximately 11:55 AM, R7 was observed lying in bed. The resident had oxygen running at 3L (liters). Oxygen tubing was observed behind both the right and left ear. […]

• Actual harm, isolatedF578May 8, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were given the opportunity to make decisions about their treatment for one (R32) of two residents reviewed for advance directives, resulting in R32 becoming distressed, tearful, and withdrawn after the facility attempted to petition (send to the hospital involuntarily for a psychiatric evaluation) him to the hospital when he refused dialysis, continuously expressing frustration with having a feeding tube, and not being included in conversations about his care. Findings include: On [DATE] at 9:28 AM, R32 was observed in bed sleeping. A tray containing breakfast was observed on the over bed table. […]

• Actual harm, isolatedF688Apr 24, 2024

  Based on observation, interview and record review, the facility failed to identify and implement interventions to address changes in range of motion (ROM) for one (R14) of two residents reviewed for limited ROM, resulting in R14 developing contractures in three fingers. Findings include: On 4/22/24 at 9:26 AM, R14 was observed lying in their bed. R14 was asked if they had any concerns about care at the facility. R14 explained when they were admitted , they could use their left hand, now it was useless and they had to keep a napkin in their palm to keep their fingernails from digging into their palm. Observation of R14's left hand revealed the middle, ring and little fingers bent down with the fingernail tips of the ring and little fingers making contact with R14's palm. […]

• Actual harm, isolatedF686May 18, 2023

  Based on observation, interview, and record review, the facility failed to ensure interventions to prevent pressure ulcers were implemented and identify and treat two new pressure ulcers for one (R24) of two residents reviewed for pressure ulcers, resulting in the development of pressure ulcers to the outside of both knees, one which had green purulent drainage and caused the resident pain. Findings include: On 5/16/23 at 8:30 AM, 9:30 AM, and 10:45 AM, R24 was observed lying on their back in bed. They had heel protector boots on both feet and their legs turned out to the sides which placed the outer aspect of their knees in direct contact with the mattress. A low air loss mattress was observed. However, the console was not turned on. […]

• No harm, potential for more than minimal, widespreadF921Jul 22, 2026

  Based on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for all residents. Findings Include:On 07/20/2026 at 9:45 AM, observed the 1st floor soiled utility room hopper sink bowl area soiled with buildup and with rust colored water. At this time the housekeeping manager (HK) H indicated it is not used by housekeeping staff and will work with the maintenance director for detail cleaning and flushing. On 07/20/2026 at 9:52 AM, observed the 1st floor central shower with dark staining of the caulk around the shower floor perimeter. […]