Three Oaks Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 11, 2025

  Based on observation, record review, and interview, the facility did not provide a resident the needed supervision and assistance to eat safely per speech therapy recommendations. The facility practice affected 1 of 3 residents reviewed (R1). R1 has cancer of the larynx (throat) and a history of dysphagia (difficulty swallowing) and aspiration pneumonia. On 02/06/25, R1's speech therapy guidelines were not followed when R1 was not given assistance and supervision at mealtime. R1 choked on sweet potatoes. R1's POA, who had just come to visit, found R1 red in the face. No staff were present. R1's POA performed the Heimlich maneuver. […]

• Immediate jeopardy, isolatedF600Mar 4, 2024

  Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from sexual abuse. The facility did not implement interventions to protect other residents (R) from sexual abuse. This affected 2 of 6 residents reviewed for sexual abuse. (R1 and R6) On 02/19/24, R2 sexually abused R1 by groping R1 under the shirt and over the bra, touching R1's breast, while in a common area. After the incident, R2 was left unsupervised and 7 minutes later sexually abused R6, groping R6's breast over her shirt. After the first incident, appropriate interventions were not implemented to prevent the second occurrence of sexual abuse from happening. R1 and R6 were found to have severe cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF814Mar 5, 2026

  Based on observation, interview, and record review, the facility did not ensure proper disposal of garbage and refuse.-Grease dumpster was open.-Cigarette butts all over the ground outside the back door.-Cardboard box with plastic and other garbage materials frozen to the ground outside the dumpster.Findings include:Facility Policy titled, Dispose of Garbage and Refuse, last revised 02/2025, reads in part: All garbage and refuse will be collected and disposed of in a safe and efficient manner .The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior of the dumpster is maintained in a manner free of rubbish or other debris .All trash will be properly disposed of in external receptacles (dumpsters) with lids covered when not… […]

• No harm, potential for more than minimal, widespreadF880Mar 5, 2026

  Based on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which had the potential to affect all 65 residents (R).-Residents were not offered hand hygiene prior to meals.-Improper use of Personal Protective Equipment (PPE) by kitchen staff.-Staff did not wear gloves and/or gown during observation of wound care for resident R10.Findings include: Example 1 Facility policy titled, Hand Hygiene, last revised 11/02/22, reads in part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.Hand hygiene is indicated and will be performed.Before and after… […]

• No harm, potential for more than minimal, widespreadF812Mar 11, 2025

  Based on observation, interview, and record review, the facility did not prepare, store, and distribute foods under sanitary conditions. The facility practice had the potential to affect all 61 residents. Floors in the kitchen, dish room and walk-in refrigerator/freezer had dirt and debris present during the initial tour of the kitchen. Carts used to transport foods and beverages to residents were discolored and had visible debris. Refrigerators in the ACU (Alzheimer's Care Unit) and East dining room, where resident foods are stored, had dried beverages and discolored ice pooled on the bottom. This is evidenced by: Example 1 The facility policy titled Food Preparation dated 9/2017. […]