Red Oak Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Red Oak Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF697Feb 27, 2023

  Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of three residents (Resident #1 and Resident #2) reviewed for pain. - 1. The facility failed to manage Resident #1's and Resident #2's pain. - - 2. The facility failed to administer Resident #1's scheduled pain medication of Tramadol at the times ordered for pain by the physician and failed to administer his PRN hydrocodone to adequately control his pain, and the facility failed to care plan pain for this resident despite it triggering on his assessment. […]

• Immediate jeopardy, patternF684Jul 2, 2021

  Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with standards of practice and based on the comprehensive assessment for 6 of 6 residents reviewed for quality of care (Residents #3, #35, #36, #39 #45, and #71#) AD F, CNA C, CNA D and CNA E gave whole popcorn to Residents #3, #35, #36, #39, #65, and #71 who were on a physician's ordered dysphagia advanced diet due to aspiration precautions. Resident #35 did not receive assistance during oral intake of popcorn per her physician's order. Staff present while the residents ate popcorn failed to intervene when 3 of 6 residents (Resident #35, 71, and #45) displayed signs of aspiration (coughing) while consuming popcorn. […]

• Immediate jeopardy, patternF689Jul 2, 2021

  Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for five (Residents #1, #25, #33, #68 and #99) of five residents reviewed for elopements. 1. Resident #99 eloped from the facility in June 2020 and was found by facility staff in the back parking lot. 2. Resident #68 eloped from the facility in February 2021 and was found by a community member in the middle of the night and returned by the police. 3. Resident #25 eloped from the facility twice in May 2021, once during the night, and was found by a community member and returned by the police. 4. Resident #33 eloped from the facility in May 2021 and was found by staff in the behind the facility. 5. […]

• Immediate jeopardy, patternF805Jul 2, 2021

  Based on observation, interview, and record review the facility failed to assure residents received and consumed foods in the appropriate form as prescribed by a physician for 5 (Residents #71, #45, #36, #39, and #3) of 5 residents reviewed for altered diet textures. AD F, CNA C, CNA D, and CNA E served regular textured popcorn to Residents #71, #45, #36, #39, and #3 who were on mechanical soft diets. Resident #45 and #71 began to cough as they ate the popcorn. This failure placed residents who required mechanically altered diets at risk for aspiration (food or liquid entering the airway), aspiration pneumonia, choking, hospitalization , and death. On 06/29/21 an Immediate Jeopardy (IJ) was identified. […]

• Immediate jeopardy, isolatedF689Aug 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and supervision.The facility failed to provide adequate supervision to prevent Resident #3, a resident with severe cognitive impairment, from exiting the facility through the front entrance during the night, and being located by local law enforcement in the roadway near a local business before being returned safely to the facility on 7/20/2026 at approximately 5:23 a.m.An Immediate Jeopardy (IJ) was identified on 08/18/2026. The IJ template was provided to the facility on [DATE] at 3:56 p.m. […]