The Oaks Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 10, 2022

  Based on observation, interview and record review, the facility failed to use a mechanical lift and two person physical assistance during a transfer from the wheelchair to bed, as specified in the resident's person centered comprehensive plan of care, for 1(#96) of 4 sampled residents reviewed for accidents (#10, #76, #71 and #96), out of total sample of 33. This failed practice resulted in an actual harm situation on 07/18/2022 at 6:00 p.m., when Resident #96, who required a mechanical lift and two-person physical assistance for transfers, was transferred from the wheelchair to bed by S4CNA without using the mechanical lift and assistance of another staff member. Resident #96 hit her left lower leg on her wheelchair during the transfer, causing a laceration that measured 30cm in length. […]

• No harm, potential for more than minimal, widespreadF809Apr 4, 2023

  Based on observation, interview and record review, the Facility failed to ensure that Residents meals were distributed in a timely manner. This deficient practice had the potential to effect all Residents that are served meals in the dining room. Findings: A review of the Facility's Frequency of Meal policy read in part . 1. Meal service times for the Residents are as follows: a. Breakfast 7:15 a.m. b. Lunch 11:30 a.m. c. Dinner 5:15 p.m. An Interview on 04/03/2023 at 7:38 a.m. with Resident #3 revealed he was sitting in dining room awaiting breakfast. Resident #3 stated that he typically eats most meals in the dining room and at times has to wait for long periods of time to receive meals. […]

• No harm, potential for more than minimal, widespreadF880Aug 26, 2021

  Based on observation, record review and interview, the facility failed to maintain infection control practices to prevent and control the spread of COVID - 19. The facility failed to discontinue indoor church services during a facility outbreak, and failed to ensure a delivery driver was screened before entering the facility, and wore a mask while onsite. This had the potential to affect all 110 residents in the facility. Findings: Interview with S1 Administrator on 08/25/2021 at 8:45 a.m. revealed he stated the facility did have residents who tested positive for COVID-19 residing on the facility's COVID-19 designated unit. He stated the facility also had staff who tested positive for COVID-19 and were currently off work on quarantine. […]

• No harm, potential for more than minimal, patternF880Jan 7, 2026

  Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff sanitized reusable medical equipment between each resident use, and performed hand hygiene after direct resident contact. Findings: Review of facility policy on 01/06/2026 at 1:30 p.m. titled Hand Hygiene Policy and Procedure dated 07/01/2020 revealed in part.Policy: Hand Hygiene shall be performed: (3) Before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. […]

• No harm, potential for more than minimal, patternF658Sep 18, 2024

  Based on interview and record review, the facility failed to ensure services were provided to residents according to accepted standards of clinical practice for 2 (Resident #97 and Resident #102) out of a total sample of 30 residents. The facility failed to notify the physician when: 1. Resident #102 had blood glucose levels greater than 451 mg/dL as ordered. 2. Resident #97 had an unwitnessed fall. Findings: Review of a facility policy titled Change in Condition Policy and Procedure dated 08/27/2018 revealed in part . Procedure: 2. The licensed nurse will assess the resident and note any signs and symptoms, including physical and mental changes in condition. Assessment may include but is not limited to: physical assessment findings, vital signs, blood glucose, oxygen saturation, etc. […]