The Oaks Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 13, 2026

  Based on record review, review of on-call notes, review of the emergency medical services (EMS) run report, review of outside hospital medical records, interview and policy review, the he facility failed to timely respond to a change in condition. This resulted in Actual Harm when on [DATE], Resident #28 had a change in condition. Facility staff failed to notify the medical provider and or respond to the change in condition. Resident #28 suffered a moderate diffuse ileus (the normal wave-like contractions of your intestines have slowed or stopped across a broad area, causing a backup of gas and fluids) which resulted in hypotension, sepsis colitis, respiratory failure, coagulopathy, volume depletion, acidosis and renal failure. Resident #38 died on [DATE]. […]

• Actual harm, isolatedF684Jul 29, 2025

  Based on medical record review, employee statement review, facility investigation review, hospital record review, employee file review, interviews and facility policy review the facility failed to timely and adequately assess and identify a major injury status post fall resulting in a delay in medical intervention. Actual harm occurred on 06/13/25 at approximately 9:30 P.M. when Resident #54, who was dependent on staff and the use of a mechanical lift for transfers, was discovered by Certified Nursing Assistant (CNA) #250 lying on the floor of her room, in front of her wheelchair. Resident #54 appeared to be in pain and was unable to recall what had occurred. […]

• Actual harm, isolatedF689Jun 25, 2024

  Based on medical record review, observation, interview, and facility policy review, the facility failed to provide appropriate assistance and follow care planned interventions for Resident #48 to prevent a fall with an injury. The facility failed to complete a fall investigation and neurological checks as ordered for Resident #29 and failed to ensure appropriate interventions were in place to prevent Resident #37 from leaving the secured unit. Actual harm occurred on 04/03/24 when Resident #48, who was severely cognitively impaired sustained a fall and fractured left hip when ambulating wearing inappropriate footwear and without her walker. […]

• Actual harm, isolatedF686Jul 17, 2023

  Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent, assess, adequately monitor and treat pressure ulcers. This affected four residents (#49, #53, #61, and #66) of four residents reviewed for pressure ulcers. The facility census was 69. Actual harm occurred on 07/11/23 when Resident #66, who was cognitively impaired, required extensive assistance from staff for bed mobility, had a pressure ulcer to the gluteal fold and had a left leg contracture was found to have a Deep Tissue Injury (DTI) (intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or… […]

• Actual harm, isolatedF697Jun 28, 2022

  Based on record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and individualized pain management program to provide adequate pain control for Resident #35. Actual harm occurred on 06/21/22 when Resident #35, who received Hospice services for terminal [CONDITION(S)], complained of continued, unrelieved pain despite scheduled and as needed narcotic pain medication doses, exhibited by verbal complaints of pain and moaning. […]