West Oaks Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at West Oaks Nursing & Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible and receives adequate supervision to prevent accidents for 1 of 2 (Resident #24) residents reviewed for accident hazards.-The facility failed to ensure Resident #24 was transferred with a one-person assist when she was a two-person assist on 3/3/2026 and sustained an injury requiring stitches. This failure could place residents at risk of injury. Findings included:Record review of Resident #24's face sheet, dated 03/10/2026, revealed a [AGE] year-old female admitted [DATE] and re-admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF756Jul 9, 2021

  Based on interview and record review the facility failed to ensure the drug regimen of each resident was reviewed at least once monthly by a Licensed Pharmacist for facility wide drug regimen review. The facility had no documentation of a drug regimen review being conducted for each resident for the months of October 2020, February 2021, and May 2021. This failure affected all residents whose medications were not reviewed for irregularities placing them at increased risk of adverse drug consequences and decline in their physical and mental health status. […]

• No harm, potential for more than minimal, patternF812Mar 13, 2026

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement.1. The facility failed to ensure leftover food to be used later with a temperature in the danger zone was discarded. 2. The facility failed to ensure leftover food past the due date was discarded.3. The facility failed to ensure that food past the use date was discarded. 4. The facility failed to ensure food was stored 6 inches off the floor.5. The facility failed to store in a separate container a scoop used for food bins in the kitchen storeroom.6. […]

• No harm, potential for more than minimal, patternF558Jan 16, 2025

  Based on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 18 residents (Resident #89, Resident #310) who were observed for call light placement. The facility failed to ensure that call light were within reach for Resident #89 and Resident #310. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: 1. Record review of Resident #89's face sheet captured on 01/16/2025 revealed a [AGE] year-old male originally admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF656Jan 16, 2025

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #6 and Resident #55) reviewed. -The facility failed to ensure that Resident #6's status of anticoagulants was a focus area in the resident's comprehensive care plan and no intervention was in place. […]