The Oaks-Brevard

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 16, 2021

  Based on record review, staff, Physician Assistant (PA) and Physician interviews, the facility failed to identify the urgent need for medical attention or notify the physician when an acute change was first identified for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 was admitted to the hospital on 05/27/21 and diagnosed with an impacted (occurs when the broken ends of the bone are jammed together by the force of the injury), angulated (where the normal axis of the bone has been altered causing the distal portion of the bone to point off in the opposite direction) and comminuted (the bone has broken into three or more pieces and in most cases, the number of bone fragments corresponds with the amount of force needed to break the bone) right femoral diaphyseal (bone… […]

• Immediate jeopardy, isolatedF689Jun 16, 2021

  Based on observations, record review and physician and staff interviews, the facility failed to prevent a cognitively impaired resident with known wandering and exiting seeking behaviors from exiting the facility unsupervised on three separate occasions. This affected 1 of 3 residents reviewed for accidents (Resident #2). While Resident #2 was outside unattended, there was a high likelihood for serious injury. The findings included: Resident #2 admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and history of falls. A care plan initiated on 01/09/21 noted Resident #2 was at risk for falls related to generalized weakness, poor safety awareness, history of falls and an actual fall on 01/09/21 with the goal he would not sustain an injury. […]

• No harm, potential for more than minimal, widespreadF680Dec 18, 2024

  Based on staff interviews, the facility failed to have a qualified professionals to direct the facility's activity program. This practice had the potential to affect all of the residents at the facility. The findings included: On 12/16/24 at 10:35 AM an interview was conducted with the Activity Director (AD). She stated that she had worked at the facility for the past several years as a nursing assistant and then became the Life Enrichment Specialist on the memory care unit around May 2023 and then moved into the AD position for the facility in December 2023 after the previous AD resigned. She stated she had never received any formal activities training from the facility, completed any state training courses, and to her knowledge was not certified. […]

• No harm, potential for more than minimal, patternF552Mar 5, 2026

  Based on record review and staff interviews, the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications prior to initiation for 6 of 6 residents reviewed for unnecessary medications (Residents #3, #7, #6, #51, #2, and #10). The findings included:1. a. Resident #3 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severe cognitive impairment. […]

• No harm, potential for more than minimal, patternF565Dec 18, 2024

  Based on record review, and resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated concerns and/or suggestions voiced by residents during Resident Council meetings for 12 of 14 months reviewed (October 2023, November 2023, January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, October 2024, and November 2024). Findings included: Review of the Resident Council Minutes for the period 10/26/23 through 11/21/24 revealed the following: a. The Resident Council meeting minutes dated 10/26/23 revealed the section for old business noted resident concerns with dietary and showers. There was no indication of the facility's response to these concerns listed under old business. […]