Oaks Nursing Home, Inc, The

In the surveyor’s words

From the most serious findings on record at Oaks Nursing Home, Inc, The, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jan 21, 2024

  Based on observations, staff interviews, and a review of the facility documents titled, Infection Control for Dietary, and Leftovers, the facility failed to ensure that items in the dry storage area, freezers, and refrigerators were labeled and dated with a use by or expiration date. The facility also failed to ensure that cell phones were not left in clean storage areas of the kitchen. This deficient practice had the potential to affect 57 of 58 residents receiving an oral diet. Findings: A review of an undated facility document titled Infection Control for Dietary, revealed, It is our practice to follow the following procedures: 4. Cover, label, and date all leftover foods stored in refrigerators. […]

• No harm, potential for more than minimal, isolatedF641Jun 19, 2025

  Based on observations, staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure two of 26 sampled residents (R) (R7 and R25) had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate assessment and care planning of the residents. Findings include: Review of the RAI Manual dated 10/01/2019 indicated, . information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. 1. […]

• No harm, potential for more than minimal, isolatedF657Jun 19, 2025

  Based on observation, staff interview, and record review, the facility failed to revise the care plan of one of 26 sampled residents (R) (R16) for the use of a bed cradle. This failure had the potential to place R16 at risk of not receiving treatment to prevent skin breakdown. Findings include: Review of R16's admission Record, located in the electronic medical records (EMR) Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinsonism, diabetes mellitus type II, dementia, and contracture of other joints. Review of R16's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/10/2025, located in the EMR MDS tab, revealed the resident had impaired cognition. […]

• No harm, potential for more than minimal, isolatedF695Jan 21, 2024

  Based on observations, staff interviews, and record review, the facility failed to monitor and clean the respiratory equipment per medical doctor (MD) orders for one resident (R) (R26). The sample size was 24 residents. Findings include: On 1/20/2024 at 3:31 pm, the facility Director of Nursing (DON) informed the survey team that the facility did not have policies related to cleaning oxygen concentrators or following MD orders. Observations on 1/19/2024 at 9:28 am and 2:41 pm and on 1/20/2024 at 7:55 am of R26's oxygen concentrator revealed the slated exterior vent cover on the back of the concentrator had obvious dust covering the slats. The interior filter was noted to be visibly dirty, with an accumulation of dust on the interior vent slats. The filter was dirty. […]

• No harm, potential for more than minimal, isolatedF803Jan 21, 2024

  Based on observations, staff interviews, and a review of the dietary menu cycle, the facility failed to ensure staff followed food recipes for preparing pureed foods for four of four residents who received a puree diet. This failure had the potential to compromise the nutritive value of tuna sandwiches for four of the four residents who received a puree diet. Findings include: During an interview on 1/20/2024 at 11:25 am, Dietary Supervisor EE was informed that recipes would be needed when observing the puree meal later in the day. The Dietary Supervisor EE reported that recipes were not used by the dietary staff. She went on to report that she had been cooking for over [AGE] years and she knew how to prepare items. […]