The Oaks

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 29, 2023

  Based on observations, record reviews and interviews the facility failed to protect the residents' right to be free from verbal abuse and mental abuse for 2 (#3 and #5) of 4 (#1, #2, #3 and #5) residents reviewed for abuse; evidenced by resident #4 used sexually inappropriate language and gestures toward resident #3 and resident #5. This deficient practice resulted in an actual harm for resident #5, who had moderate cognitive impairment, on 10/18/2023 at 1:15 p.m. when resident #4 made an inappropriate sexual comment and gesture to resident #5. This resulted in resident #5 becoming upset and crying. Resident #5 was assisted to her room and was consoled by staff. […]

• No harm, potential for more than minimal, patternF552Jun 11, 2025

  Based on record reviews, and interviews the facility failed to ensure residents were informed of the risks, benefits and side effects of psychotropic medications for 6 (#19, #38, #25, #30, #43, #5) of 6 (#19, #38, #25, #30, #43, #5) residents reviewed for unnecessary medications. Findings: Resident #38 Review of the medical record for Resident #38 revealed she had an admitted [DATE] with diagnoses which included anxiety and depression. Review of the physician orders revealed Resident #38 received the psychotropic medications Alprazolam 0.25 milligrams (mg) daily and Olanzapine 5 mg daily for the treatment of anxiety and Sertraline 50 mg daily for the treatment of depression. […]

• No harm, potential for more than minimal, patternF605Jun 11, 2025

  Based on record reviews and interviews, the facility failed to ensure residents that received psychotropic drugs had a gradual dose reductions, and residents that had orders for psychotropic medications as needed (PRN) were not subjected to chemical restraints for 2 (#5, #19) of 6 (#5, #19, #25, #30, #38, #43) residents reviewed for unnecessary medications. The facility failed to ensure: 1). A resident that was on psychotropic drugs received gradual dose reductions (#19); and 2). PRN orders for psychotropic drugs were limited to 14 days (#5, #19). Findings: Resident #19: Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including vascular dementia, generalized anxiety disorder, and chronic obstructive pulmonary disease. […]

• No harm, potential for more than minimal, patternF689Jun 11, 2025

  Based on observations, interviews, and record reviews the facility failed to ensure adequate supervision and assistive devices to prevent accidents were in place for 1 (#23) of 5 (#5, #11, #14, #23, #30) residents investigated for accidents. The failed practice was evidenced by Resident #23 being identified as an unsafe smoker, she was observed smoking without a smoking apron, and was observed having smoking articles in her possession without direct supervision. Findings: Review of the facility`s Smoking Policy, with a revision date of June 2024, revealed in part the following: 4. All unsafe smoking residents shall wear a smoking apron while smoking in the designated smoking area. 15. Smoking articles for residents without independent smoking privileges: a. […]

• No harm, potential for more than minimal, patternF882Jun 11, 2025

  Based on record review and interviews the facility failed to ensure the Infection Preventionist, who was responsible for the facility's infection prevention and control program, had completed specialized training in infection prevention and control. Findings: Review of the facility's Infection Control Records revealed there was no documented evidence the Infection Preventionist, S5Licensed Practical Nurse (LPN), had completed specialized training in infection prevention and control. On 06/10/2025 at 9:50 a.m. an interview with S5LPN revealed she did not have any specialized training in infection prevention. On 06/10/2025 at 1:10 p.m. an interview with S2Director of Nursing (DON) confirmed the facility did not have a nurse that had received specialized training in infection prevention.