Presidential Oaks

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Jan 30, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) in 2 of 2 residents reviewed for pressure ulcers (Resident Identifiers are #55 and #30). The facility failed to follow hand hygiene policy with 1 of 1 dressing change observation (Resident identifier is #55). The facility failed to follow identified interventions for water management: legionella prevention and update Infection Prevention Policies annually.Findings include: Resident #30 Review on 1/30/26 of Resident #30's wound note, dated 1/29/26, revealed a stage II pressure ulcer to the left heel and a stage II pressure ulcer to the sacrum. […]

• No harm, potential for more than minimal, patternF881Jan 30, 2026

  Based on interview and record review, it was determined that the facility failed to implement a system to monitor antibiotic use use for 3 of 5 resident's reviewed in a final sample of 18 residents (Resident identifiers are #11, #57, and #7).Findings include:Review on 1/30/2026 of facility policy titled Antibiotic Stewardship Program undated revealed .Policy Interpretation and Implementation.to improve the use of antibiotics in an effort to decrease antibiotic resistant organisms. […]

• No harm, potential for more than minimal, patternF758Nov 5, 2021

  Based on interview and record review, it was determined that the facility failed to ensure that PRN (as needed) orders for [CONDITION(S)] drugs are limited to 14 days or had physician rationale with the duration for the PRN order indicated for 4 residents out of 7 residents reviewed for unnecessary medications in a final sample of 14 residents. (Resident identifiers #3, #11, #17 and #32.) Findings include: Resident #3 Review on 11/3/21 of Resident #3's current physician's orders revealed an order for Lorazepam (anti-anxiety) 0.5 mg (milligram) by mouth every 4 hours PRN (as needed) without a start date and an indicated duration of use. […]

• No harm, potential for more than minimal, patternF880Nov 5, 2021

  Based on interview and record review, it was determined that the facility failed to ensure that COVID-19 screenings for residents were completed per CDC guidelines for 4 out of 5 residents reviewed for resident COVID-19 assessments. (Resident identifiers are #1, #8, #9, and #25.) Findings include: Review on 11/4/21 of the CDC website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated on 9/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed, .Evaluate Residents at least Daily .Actively monitor all residents upon admission and at least daily for fever (temperature ?100.0°F) and symptoms consistent with COVID-19 .symptoms of COVID-19: Fever, Cough, Shortness of breath or… […]

• No harm, potential for more than minimal, isolatedF565Jan 30, 2026

  Based on observation, interview and record review, it was determined that the facility failed to ensure that residents were provided with a private space for a resident group to meet on a regular basis, make residents aware of upcoming meeting and to make prompt efforts to resolve resident and group grievances, keep residents apprised of the progress towards resolution, and maintain evidence demonstrating the response and rationale for the response for 6 residents out of a facility census of 71 (Resident identifiers are #6, #14, #26, #30, #41 and #54).Findings include:Interview on 1/28/26 at approximately 8:15 a.m. with Staff D (Administrator in Training) revealed that the Resident Council president was not a long term resident. […]