Scarlet Oaks Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 22, 2022

  Based on medical record review, observation, staff interview, resident interview, and review of the facility smoking policy, the facility failed to ensure Resident #29 exhibited safe smoking practices, stored his smoking materials appropriately, and did not smoke while near oxygen. This resulted in Immediate Jeopardy and the potential for serious injury, harm, impairment, and/or death, on 08/10/22 when Resident #29, who utilized oxygen therapy, was found outside the building, in the facility's designated smoking area, smoking with his oxygen on. This affected one (Resident #29) out of three residents reviewed for smoking. […]

• Actual harm, isolatedF686Jul 12, 2023

  Based on record review, observation, staff interview, review of facility policy, and review of guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin and failed to timely identify a resident's pressure ulcer until it reached an advanced stage which resulted in actual harm to Resident #37 who was admitted to the facility without pressure ulcers and developed an unstageable pressure ulcer to the right heel. The facility also failed to ensure pressure ulcer treatments were administered per the physician's order which placed the resident at risk for more than potential harm that was not actual harm. This affected two (Residents #04 and #37) of three residents reviewed for pressure ulcers. The facility census was 67. […]

• Actual harm, isolatedF686Mar 15, 2021

  Based on record review, observation, interview, policy review and review of the National Pressure Injury Advisory Panel (NPIAP) recommendations, the facility failed to ensure two residents (Residents #61 and #155) received adequate care, monitoring, and treatment to prevent the development and decline in pressure ulcers. This resulted in actual harm when Resident #61 was found to have an avoidable unstageable wound to the right heel, a deep tissue injury (DTI) to the left heel and a sacral wound that had increased in size. In addition Resident #155 had a a stage two pressure ulcer on admission that declined to an unstageable pressure ulcer. This affected two of three residents reviewed for pressure ulcers. The facility identified two pressure ulcers in the facility. […]

• Actual harm, isolatedF760Mar 15, 2021

  Based on closed and open medical record review, hospital record review, Self-Reported Incident (SRI) review, staff interview, review of staff statements, review of a personnel file, and facility policy review the facility failed to ensure medications were transcribed correctly upon admission/readmission from the hospital. This resulted in actual harm to Resident #149 when Licensed Practical Nurse (LPN) #150 did not transcribe anticonvulsant medications correctly upon the residents return from the hospital for [MEDICAL CONDITION] activity. Resident #149 experienced convulsions within three days of readmission and was readmitted to the hospital's neurology unit. […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2025

  Based on observation, staff interview, and policy review, the facility failed to ensure food was stored and served in accordance with professional standards for food safety. This deficient practice had the potential to affect all 65 residents who received food from the kitchen. The facility census was 65. Findings included: Observations, during initial tour of the kitchen, on 01/20/25 from 8:50 A.M. to 9:10 A.M., with the facility's Dietary Manager (DM) revealed the following: one 5-pound bag of frozen tater tots that was not in the original packaging and not labeled or dated with a use-by date in the walk-in freezer; one 16-ounce bag of broccoli that was not in the original package and was not labeled or dated with a use-by date in the walk-in freezer; one 5-pound container of peanut… […]