Red Oak Rehab and Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 26, 2021

  Based on observation, staff interview, and record review, the facility failed to protect residents against burn hazards from the baseboard heating elements in their rooms for 1 of 6 residents reviewed. All 6 of the residents in the sample occupied beds facility staff had placed in a parallel position next to the baseboard heaters under the windows in their rooms. Resident #13 had a diagnosis of [CONDITION(S)] and utilized an adjustable bed next his in-room heating element. On 3/16/21 at 2:10 PM, staff found Resident #13 on the floor between his bed and the wall. His backside lay against the baseboard heater, which resulted in 1st and 2nd degree [CONDITION(S)]. These findings constituted an Immediate Jeopardy (IJ) to the residents' health and safety. […]

• Immediate jeopardy, isolatedF740Aug 20, 2026

  Based on clinical record review, Medical Examiner records, staff interviews, first responder interviews, and policy review the facility failed to meet 1 of 3 resident's mental health needs (Resident #1), when they did not intervene per her care plan with her comments of wanting to die and did not update the provider of the ongoing comments. Resident #1 had diagnoses of depression, dementia with agitation, other symptoms/signs involving appearance and behavior, and altered mental status. The resident presented with a history of suicidal ideations, previous attempts while at the facility. The facility failed to notify the provider of the continued comments of wanting to die. […]

• Actual harm, isolatedF689Jul 20, 2024

  Based on clinical record review, resident interview, staff interviews, equipment manual review, and policy review the facility failed to maintain patient care equipment in safe operating conditions by not completing safety and maintenance checks allowing the actuator mount to wear and break causing the resident to fall to the floor and sustain a compression fracture for 1 of 3 residents (Resident #2) reviewed. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. […]

• Actual harm, isolatedF689Jun 13, 2024

  Based on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to transfer 1 of 3 resident (Resident #1) safely to prevent her from falling. Staff failed to obtain a gait belt prior to assisting Resident #1 from the toilet to the sink to wash her hands. Instead staff held on to the resident's pants during the transfer. As Resident #1 turned away from the sink, she lost balance, staff lost grip and the resident fell on her right shoulder. The resident was sent to the emergency room (ER) to be evaluated and was found to have a right proximal humerus fracture. The resident returned to the facility the same day with her right arm in a sling and recommendations to follow up with orthopedics. […]

• No harm, potential for more than minimal, widespreadF727Oct 24, 2024

  Based on document review, staff interview and facility policy review the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 11 of 90 days reviewed (April 1st through June 30th 2024). The facility reported a census of 25 residents. Findings include: Review of the Payroll Based Journal (PBJ) staffing data report for the fiscal year quarter three (April 1st through June 30th, 2024) revealed there was no Registered Nurse (RN) hours for 4/29, 5/4, 5/18, 5/23, 5/31, 6/1, 6/2, 6/11, 6/15, 6/16, and 6/25/2024. Interview 10/22/24 at 12:52 PM with the Administrator confirmed that the facility did not have RN coverage listed on the PBJ. […]