Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Village during CMS and state inspections, most recent first.
The facility failed to develop and implement complete care plans for several residents based on current status. A resident with stage 3 pressure ulcers lacked a specific wound care plan, another resident taking aspirin lacked an antiplatelet care plan, and a resident with cannabis smoking behavior had no behavior care plan despite nursing notes documenting marijuana vape use. The facility also did not follow existing fall interventions for residents with severe cognitive impairment, including missing wheelchair activity supports, lack of Dycem, and improper footwear.
Care plans were not kept current for several residents. One resident’s plans still listed Eliquis and pneumonia treatment after those meds were discontinued, another resident’s anticonvulsant and falls plans were not revised after Depakote was stopped and the resident was moved to a peddle Broda chair, a third resident’s shingles plan remained active without a current shingles dx, and a fourth resident’s pressure ulcer plan stayed in place after the area healed. An LPN stated care plans should be updated quarterly and as needed.
Unsafe handling of catheter tubing, oxygen tubing, and clean linen. A resident with an indwelling urinary catheter was repeatedly observed in a wheelchair with the catheter tubing and drainage bag dragging on the floor, including in common areas and while moving to the dining room. Another resident was observed with oxygen tubing resting on the floor and against the wheelchair wheel, and a laundry staff member was seen placing clean linen against her uniform top while moving it to the linen closet.
A resident with MS missed neurologist appointments for Botox injections because the facility did not arrange transportation. The resident reported severe leg pain and said her appointment was cancelled due to transportation issues, leaving her to wait until the next available neurology visit. Nursing notes showed attempts to reschedule, and the neurologist's office confirmed the appointment was moved because transportation was not set up.
A resident with dementia, depression, and bipolar disorder had repeated behavioral incidents involving yelling, cursing, threats, and a physical gesture toward another resident, but the chart lacked a physician order for behavior monitoring and lacked documentation of provider notification for the incidents. The record also had no IDT notes related to behaviors, while care plan conferences and a psych note documented no behavior concerns despite the resident’s escalating outbursts.
Pharmaceutical services failed to meet resident needs when ordered meds were not available for administration. A resident with dementia, anxiety, depression, and recent hip surgery missed doses of aspirin, Breo Ellipta, and Lovenox because the meds were not in the facility, were waiting for delivery, or were to be picked up by family, and there was no documentation of pharmacy, MD, DON, administrator, or social services notification. Another resident also missed Vitamin D3 doses because the med was on hold or unavailable from the pharmacy.
Smoking evaluations were not completed quarterly for two residents who currently smoked. One resident had DM2, tobacco use, and PVD, and the other had MS, leg pain, and tobacco dependence; both were cognitively intact but dependent on staff for some ADLs. An LPN confirmed the residents smoked at the facility and stated smoking evaluations should be done quarterly and as needed, while the facility policy required quarterly review of smoking privileges.
Surveyors observed that food items in the kitchen freezer were left open, undated, and unlabeled, and that kitchen areas had visible dust and debris. During meal service, a staff member assisted multiple residents without performing required hand hygiene between contacts, contrary to facility policy.
A nurse preset medications prior to administration, resulting in a resident with multiple medical conditions receiving another resident's medications. The error was identified after the nurse realized the mistake, and the resident required hospital evaluation and IV fluids for hypotension.
The facility failed to serve meals at safe and appetizing temperatures, as observed during a survey. A lunch tray on the 100 hall contained food items below the required temperatures, with chicken strips at 80°F, French fries at 90°F, slaw at 70°F, and applesauce at 55°F. Residents expressed dissatisfaction, noting cold and unappetizing food, and Resident Council minutes highlighted ongoing concerns about food temperatures and repetitive meal options.
The facility failed to store and label food according to professional standards. During a kitchen observation, a freezer contained unsealed and unlabeled frozen vegetables, fish fillets, and meatballs. A refrigerator had an unmarked container of pasta salad. A dietary aide confirmed the requirement for labeling and dating all food items and discarded the unlabeled pasta salad.
A facility failed to maintain accurate controlled drug records for a resident with severe cognitive impairment receiving opioid medications. Discrepancies were found between the medication administration record and the controlled substance count log for Norco 5-325 mg. Interviews revealed a lack of awareness and explanation for these inconsistencies, with staff indicating that both routine and as-needed orders were counted on the same sheet, contributing to the issue.
The facility failed to provide scheduled activities for residents when the Activity Director was absent, affecting several residents. Residents expressed dissatisfaction with the lack of activities, particularly on weekends. Staffing issues contributed to the deficiency, as CNAs were often pulled to work on the floor, leaving no one to conduct activities. Despite residents' medical conditions, they expressed a desire to participate in group activities, which were not being provided consistently.
A facility failed to document post-dialysis vital signs for a resident with end-stage renal disease, despite policy requirements. Additionally, the facility did not document medication administration for several residents, with MARs lacking records of administered medications on specific dates. Interviews revealed that the night shift nurse was not completing documentation as required, indicating a lapse in following established protocols.
The facility failed to create a care plan for a resident with dementia and did not implement person-centered interventions for another resident with dementia and agitation. The care plans were generic and lacked specific, individualized interventions, contrary to the facility's policies.
The facility failed to conduct quarterly care plan meetings for three residents, as required. One resident reported not remembering attending a meeting recently, with records showing only one meeting in the last year. Another resident was unaware of any meetings, with only two documented in the past year. A third resident recalled attending only one meeting, confirmed by records. The SSD acknowledged being behind on scheduling meetings, and the facility's policy requiring a seven-day advance notice was not followed.
A resident with severe cognitive deficit and a history of femur fracture experienced a fall and complained of leg pain. Despite a high pain assessment score, there was a delay in notifying the physician and obtaining necessary medical orders. The resident was eventually sent to the hospital, where an x-ray confirmed a femoral neck fracture.
A resident with a severe cognitive deficit and pressure ulcers experienced significant pain during a dressing change, as the nursing staff failed to pre-medicate or adequately address her pain despite her verbal and non-verbal expressions of discomfort. The resident's care plan and facility policy on pain management were not effectively followed, leading to a deficiency in providing appropriate pain relief.
The facility failed to dispose of expired medications, including an insulin vial and a flu vaccine, as per their policies. An LPN and the RDCS confirmed the insulin was expired, and the DON acknowledged the expired flu vaccine. The facility's policy requires outdated drugs to be returned or destroyed.
The facility failed to ensure the use of facial hair restraints in the kitchen, as observed during inspections. The Dietary Manager was seen with a visible mustache without a hair restraint while preparing food and checking temperatures. The DM believed facial hair coverings were only necessary for full beards, contrary to the facility's policy requiring restraints for long facial hair.
Incomplete and Unimplemented Care Plans for Wounds, Medications, Behaviors, and Falls
Penalty
Summary
The facility failed to develop and implement complete, current care plans for multiple residents based on their assessed needs and current status. Resident 28 had three stage 3 pressure ulcers, including a right buttock wound first identified after return from the hospital, but the clinical record lacked a specific care plan for that pressure area. The record also showed physician-ordered wound treatment for the coccyx and ongoing wound measurements, while RN staff stated that care plans should be specific and reflect current status and that each pressure area should have its own care plan. The facility also lacked current care plans for other resident needs and conditions. Resident 1, who had diabetes, anxiety, and peripheral vascular disease, was taking aspirin 81 mg daily for peripheral vascular disease, but the clinical record lacked a current antiplatelet care plan. Resident 9, who had multiple sclerosis, pain in both legs, and tobacco dependence, had nursing notes documenting marijuana vape pen use and a strong smell of pot at the back door with staff obtaining a vape pen from the resident, yet the record lacked a plan of care for the cannabis smoking behavior. The SSD stated the resident should have been care planned for smoking cannabis behavior, and an LPN stated behaviors and medications should be included in care plans. The facility also failed to follow existing care plan interventions for residents with fall-related needs. Resident 5, who had severe cognitive impairment and was dependent on staff for toileting, bathing, bed mobility, and transfers, had a falls care plan that included transferring the resident to the dining room last, providing resident-focused activities while in the wheelchair, and placing Dycem on the wheelchair, but staff were observed transferring the resident without the non-skid layer and the resident had no activities available while seated in the wheelchair. Resident 30, who had dementia, stroke, anxiety, severe cognitive impairment, dependence for footwear and transfers, and two falls without injury since the prior assessment, had a falls care plan requiring appropriate footwear such as non-skid socks when ambulating or mobilizing in a wheelchair, yet was observed wearing regular grey socks while seated in a pedal Broda chair.
Care Plans Not Updated to Reflect Current Resident Status
Penalty
Summary
The facility failed to keep resident care plans current to reflect changes in residents’ conditions and medications. Review of records showed that one resident’s anticoagulant care plan for Eliquis remained in place even though the medication had been discontinued, and a care plan for shortness of breath related to pneumonia still included an intervention to administer Augmentin after the antibiotic had been stopped. The resident’s most recent MDS indicated the resident was cognitively intact and not taking an anticoagulant, while the medication orders showed Eliquis had been discontinued and Augmentin had been ordered only for a 5-day course for pneumonia. Another resident’s care plan for anticonvulsant use remained active even though Depakote had been discontinued, and the falls care plan was not revised to reflect current interventions after the resident was moved from a wheelchair to a peddle Broda chair. The resident’s record showed severe cognitive impairment, dependence for transfers, and two falls without injury since the prior assessment. An IDT note documented discussion of the fall, the resident being placed by the nurse’s station for increased monitoring, and the use of a peddle Broda chair per therapy, but the current falls care plan still listed interventions tied to wheelchair use. A third resident’s care plan for shingles remained active even though the record did not show a current diagnosis of shingles, and the most recent note identifying shingles was dated earlier in the stay. A fourth resident’s pressure ulcer care plan remained for a bilateral buttock unstageable pressure ulcer even though wound evaluations showed that area had healed, while the resident currently had three stage 3 pressure ulcers. The facility’s care plan policy stated that care plans are revised as resident assessments and conditions change, and an LPN stated care plans should be updated quarterly and as needed.
Unsafe handling of catheter tubing, oxygen tubing, and clean linen
Penalty
Summary
The facility failed to ensure a safe, sanitary, and comfortable environment when a resident with an indwelling urinary catheter was observed multiple times with the catheter tubing and drainage bag dragging on the floor. Resident 23, who had diagnoses including urinary retention and hemiplegia/hemiparesis following a stroke, was seen propelling himself in a wheelchair with the catheter tube dragging under his shoe and hitting the floor, later with the catheter bag dragging the floor in the common area and activity room, and again with the bag dragging the floor while heading to the dining room. The resident’s quarterly MDS indicated he was cognitively intact, had an indwelling catheter, and was totally dependent on staff for transfers and toileting. The facility also failed to maintain sanitary handling of clean linen and oxygen tubing. Laundry 9 was observed taking clean linen from a cart and placing it against her uniform top before putting it into the linen closet. Resident 4 was observed sitting with oxygen tubing resting on the floor and lying against the inside right wheel of the wheelchair. The DON stated that oxygen tubing observed dragging or resting on the floor should be picked up and changed out, and that clean linen should be carried away from the body so it does not rub against staff uniform tops. Current facility policies stated that oxygen tubing should follow infection control practices, clean linen should be handled to remain hygienically clean and separated from soiled linen, and catheter tubing and drainage bags should be kept off the floor.
Missed Neurology Appointments Due to Lack of Transportation
Penalty
Summary
The facility failed to ensure transportation was provided for a resident to attend neurologist appointments for Botox injections related to multiple sclerosis. The resident was cognitively intact and dependent on staff for toileting, showering, and transfers. Her current physician orders included a neurologist appointment, and her care plan for impaired neurological function related to MS included an intervention to assist with transportation to follow-up neurology appointments. During the survey, the resident stated her legs hurt badly and that her last neurologist appointment had been cancelled by the facility because of transportation issues, leaving her to wait until February for her next Botox injection. Facility nursing notes documented attempts to contact the neurologist's office to reschedule the Botox appointment, and a medication note recorded the resident's complaint of leg pain due to not receiving the injection. An LPN stated the resident received Botox every 3 to 4 months, that nursing staff were responsible for scheduling appointments, and that transportation was coordinated by a scheduler who was on vacation during the survey period. The neurologist's office confirmed the November appointment was rescheduled by the facility due to lack of transportation and that February was the first available appointment after the missed injection.
Failure to Monitor Escalating Resident Behaviors
Penalty
Summary
The facility failed to ensure behavior monitoring for one resident with a history of dementia, depression, and bipolar disorder. The resident’s clinical record showed no physician’s order to monitor behaviors, and the most recent quarterly MDS indicated no cognitive impairment and no behaviors. However, the record contained behavior care plans related to prior medication changes, a roommate change, and threats of self-harm and suicide, along with multiple behavior progress notes documenting escalating incidents with other residents and staff. The documented behaviors included a verbal altercation in April in which the resident remained upset after being separated from another resident, an August incident in which the resident yelled, cursed, and threatened to hit another resident and then threatened to hit a nurse, and a December incident in which the resident cursed at another resident, swung a fist without making contact, and was placed on 15-minute checks. The record lacked documentation of physician or psychiatric provider notification for these incidents, and there were no interdisciplinary notes related to behaviors for the last 12 months. Care plan conferences during the year documented no behavior concerns, and a psychiatric visit note stated no behaviors were reported by facility staff. Staff interviews indicated behavior information was being tracked through a TAR only when ordered or through a behavior log binder, and the SSD later stated the resident was in need of a behavior monitoring care plan.
Medications Not Available for Ordered Administration
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of residents when medications were not available to be administered as prescribed. For Resident 4, whose diagnoses included status post hip surgery, dementia, anxiety, and depression, the clinical record showed a severe cognitive impairment on the most recent significant change MDS assessment. Physician orders included aspirin 81 mg every 3 days, Breo Ellipta inhalation aerosol powder daily, and Lovenox 40 mg daily for 28 administrations. The MAR showed aspirin was not given on the scheduled date because family was to pick it up from the pharmacy, and Breo Ellipta was not administered on multiple dates because it was not available, waiting for delivery, or to be picked up by family. Lovenox was also not administered on multiple dates because there was no supply available, it was not in the cart or refrigerator, or family had not delivered it.
Smoking evaluations not completed quarterly for two residents
Penalty
Summary
The facility failed to ensure its smoking policy was implemented for 2 of 2 residents reviewed for smoking because their smoking evaluations were not completed quarterly. Resident 1 had diagnoses including diabetes mellitus type II, tobacco use, and peripheral vascular disease, was cognitively intact, and was dependent on staff for transfers and toileting. Resident 1 had a Smoking Care Plan last revised on 6/19/23, and the last smoking evaluation in the record was completed on 3/25/25. Resident 9 had diagnoses including Multiple Sclerosis, pain in both legs, and tobacco dependence, was cognitively intact, and was dependent on staff for toileting, showers, and transfers. Resident 9 had a Smoking Care Plan last revised on 2/15/23, and the last smoking evaluation in the record was completed on 2/21/25. An LPN stated that both residents currently smoked at the facility and that smoking evaluations should be completed quarterly and as needed; if they were not done quarterly, they had been missed. The facility's smoking policy stated that all residents who smoke would be supervised, smoking-related issues would be noted on the care plan, and the staff would review smoking privileges quarterly and with significant changes.
Failure to Maintain Food Safety Standards and Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to store and distribute food in accordance with professional standards for food service safety, as observed during a kitchen inspection. Multiple food items in the reach-in freezer, including peas, broccoli, cookie dough, pancakes, meat patties, and hashbrowns, were found open to air, undated, and unlabeled. Additionally, the kitchen floor under the stove and around the base of the walls had a buildup of dust and debris, ceiling vents and panels above food preparation areas were dusty, and the top of the dishwasher contained dust, debris, and food crumbs. The Dietary Manager confirmed that frozen food should be labeled, dated, and sealed, and that routine cleaning was not documented in a cleaning log, despite a recent deep clean. During meal service, a staff member was observed touching a resident's hair, another resident's shoulder, and then a third resident's cup without performing hand hygiene between contacts. Facility policy requires staff to perform hand hygiene after touching residents and after delivering each tray of food, but this was not followed. The facility's own policies on food storage, cleaning, and hand washing were not adhered to during these observed events.
Medication Administration Error Due to Presetting Medications
Penalty
Summary
A nurse preset medications for multiple residents prior to the medication pass, resulting in a resident receiving another resident's medications. The error was discovered when the nurse returned to the medication cart and realized that the intended medications for the resident were still present, while another resident's medications had been administered in error. The facility's Director of Nursing confirmed that staff should not preset medications and must always verify the correct medications are given to the correct resident. The affected resident had a medical history including paraplegia, anemia, depression, and seizures, and was care planned for gastrointestinal and neurological issues requiring medications as ordered. After receiving the incorrect medications, the resident reported feeling unwell and was found to be hypotensive, requiring transfer to the hospital for intravenous fluids and further observation. The incident was documented in both facility and hospital records.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide appetizing and palatable meals, as evidenced by observations and resident complaints. During a survey, it was noted that the lunch trays served on the 100 hall contained food items that were not at appropriate temperatures. Specifically, chicken strips were served at 80 degrees Fahrenheit, French fries at 90 degrees Fahrenheit, slaw at 70 degrees Fahrenheit, and applesauce at 55 degrees Fahrenheit. These temperatures did not meet the facility's policy requirements, which state that hot food should be served at a minimum of 135 degrees Fahrenheit and cold food at 41 degrees Fahrenheit or below. Residents expressed dissatisfaction with the meals, citing issues with cold and unappetizing food. Resident J and Resident M both reported disliking the food, with Resident M specifically mentioning that hot food was often served cold. Resident Council minutes also reflected ongoing concerns about food temperatures and repetitive meal options, such as chicken strips and French fries being served three times in seven days. During an interview, Resident P described the French fries as terrible, cold, and hard. These findings indicate a failure to adhere to the facility's food temperature policy, resulting in unappetizing and potentially unsafe meals for residents.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to ensure food was stored and distributed in accordance with professional standards for food service safety. During a kitchen observation, a standing reach-in freezer was found to contain a box of frozen vegetables that was not sealed, and a bag of frozen vegetables was open to air. Additionally, a bag of what appeared to be frozen fish fillets and a bag of what appeared to be meatballs were not labeled. In the reach-in refrigerator, there was an unmarked container of what appeared to be pasta salad. During an interview, a dietary aide confirmed that all food items should be labeled and dated, and any unlabeled or undated food must be discarded. The dietary aide then discarded the unlabeled pasta salad. The facility's policy, dated November 2024, requires leftover food to be stored in covered containers or wrapped securely, with each item clearly labeled and dated.
Inaccurate Controlled Drug Records for a Resident
Penalty
Summary
The facility failed to maintain accurate controlled drug records for one of the three residents reviewed for pharmaceutical services. Specifically, the controlled substance count sheets did not match the documented administration of controlled drugs for Resident B over a 30-day review period. Resident B, who had severe cognitive impairment and was receiving opioid medications, had discrepancies in the records for Norco 5-325 mg. On several occasions, the medication administration record (MAR) did not align with the controlled substance count log, indicating either missing documentation of administration or discrepancies in the count log. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) revealed a lack of awareness and explanation for these inconsistencies. The DON was unaware of any issues with controlled substance counts, and LPNs indicated that both routine and as-needed orders were counted on the same sheet, which may have contributed to the discrepancies. The facility's policy on charting and documentation required that all services, including medication administration, be documented in the resident's medical record, but this was not adhered to in the case of Resident B.
Facility Fails to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide scheduled activities for residents when the Activity Director was absent, affecting 6 out of 7 residents reviewed. Residents expressed dissatisfaction with the lack of activities, particularly on weekends and when the Activity Director was unavailable. The activities calendar posted in the facility indicated scheduled activities, but these were not observed to have taken place. Interviews with residents revealed that they missed the previous staff and were bored due to the lack of engaging activities. The facility's staffing issues contributed to the deficiency, as Certified Nursing Assistants (CNAs) who were supposed to fill in for the Activity Director were often pulled to work on the floor, leaving no one to conduct activities. The Activity Director was frequently absent due to schooling commitments, and the facility had not replaced a long-time Activity Assistant who had quit. This resulted in a significant reduction in the number of activities available to residents, particularly on weekends and evenings. Residents' medical profiles indicated various conditions, including dementia, multiple sclerosis, diabetes, and chronic kidney disease, with most residents being cognitively intact. Despite their conditions, residents expressed a desire to participate in group activities, which were not being provided consistently. The facility's policy on activities was not being adhered to, as evidenced by the lack of documented participation in scheduled activities on the residents' individual activity task forms.
Failure to Document Post-Dialysis Vital Signs and Medication Administration
Penalty
Summary
The facility failed to document post-dialysis vital signs for a resident with end-stage renal disease who required dialysis treatment. The resident's records showed multiple instances from April to September 2024 where post-dialysis vital signs were not documented, despite the facility's policy requiring such documentation. The Regional Director of Clinical Services confirmed the absence of these vital signs in the resident's electronic medical record, indicating a failure to adhere to the facility's policy. Additionally, the facility did not document the administration of medications for several residents as required. For one resident, the medication administration records (MARs) for August and September 2024 lacked documentation of the administration of multiple medications, including omeprazole, metoprolol tartrate, and levothyroxine sodium, on specific dates. There was no documentation of resident refusal for these medications. Similar issues were found for other residents, where MARs lacked documentation of medication administration for various prescribed drugs, again without any record of resident refusal. Interviews with the Regional Director of Clinical Services and a Licensed Practical Nurse revealed that the night shift nurse was not completing documentation as required by the facility's policy. The policy mandates that documentation should be completed immediately after medication administration by the licensed personnel who administer the medication. The failure to document medication administration and post-dialysis vital signs indicates a significant lapse in following established protocols for resident care.
Deficiencies in Dementia Care Planning
Penalty
Summary
The facility failed to create a care plan for a resident with dementia, as required by the Preadmission Screening and Resident Review (PASRR) process. Resident 2, who had a diagnosis of dementia with unspecified severity, was identified as needing a Level II evaluation. However, the facility did not have any documentation of a care plan addressing the resident's dementia or cognitive needs. The Regional Director of Clinical Services confirmed the absence of such a care plan, despite the resident's diagnosis necessitating one. Additionally, the facility did not implement person-centered dementia care plan interventions for another resident, Resident 21, who had dementia with agitation and psychotic disturbance. The care plans in place for this resident were generic and lacked specific, individualized interventions. The interim Director of Nursing acknowledged that the care plans did not contain any information specific to the resident, and the staff assignment sheets also lacked person-centered information or interventions. The facility's policies on care planning and interventions were not followed, as evidenced by the lack of individualized care plans for residents with dementia. The policies required the interdisciplinary team to develop individualized care plans and incorporate the resident's personal and cultural preferences, as well as targeted and meaningful interventions. However, these requirements were not met for the residents reviewed, leading to deficiencies in their care plans.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for three residents, as required. Resident 3 reported not remembering being invited to or attending a care plan meeting recently, and her records showed only one care plan meeting in the last year, despite having no cognitive impairment. The Social Service Director (SSD) confirmed the lack of documentation for quarterly meetings and acknowledged being behind on scheduling them. Similarly, Resident 6 was unaware of any care plan meetings and had only two documented meetings in the past year. Resident 12 also recalled attending only one meeting during her stay, with records confirming just one meeting in the last year. The SSD could not provide additional documentation for these residents, and the facility's policy required a seven-day advance notice for care plan conferences, which was not adhered to.
Delay in Treatment Following Resident Fall
Penalty
Summary
The facility failed to ensure timely treatment for a resident who experienced a fall and subsequent pain. Resident 18, who had a history of severe cognitive deficit, a fracture of the left femur, and pressure ulcers, fell on 7/4/24 and complained of left leg pain. Despite the resident's complaints and a pain assessment score of 8 out of 10, there was a delay in notifying the physician and obtaining necessary medical orders. Initial assessments noted no visible injuries, but the resident continued to experience pain, which was not promptly addressed. The nursing staff left messages for the physician and the Director of Nursing but did not receive a timely response. It was not until 7/5/24 that the physician was notified, and an x-ray was ordered, which was not completed that day. The resident was eventually sent to the hospital on 7/6/24, where an x-ray confirmed a left femoral neck fracture. The delay in treatment and lack of immediate action following the fall contributed to the deficiency identified in the report.
Inadequate Pain Management During Dressing Change
Penalty
Summary
The facility failed to provide adequate pain management for a resident during a pressure ulcer dressing change. On the morning of 9/20/24, Resident 18, who has a severe cognitive deficit and a history of pressure ulcers, was observed experiencing significant pain during a dressing change on her left heel. Despite the resident's verbal and non-verbal expressions of pain, such as wincing, clenching her jaw, and moving her foot away, the nurses continued with the procedure. It was later revealed that the resident had not been pre-medicated with pain relief prior to the dressing change, contrary to what was initially indicated by RN 13. The resident's medical records showed a history of complaints of pain during previous dressing changes, with pain assessments indicating a score of 6 out of 10. The care plan for the resident included interventions to anticipate and respond to pain, but these were not effectively implemented during the dressing change. Interviews with the nursing staff confirmed that the resident was given a pain pill only after the procedure was completed. The facility's policy on pain assessment and management was not adhered to, as the staff failed to recognize and adequately address the resident's pain during the dressing change.
Expired Medications Not Properly Disposed
Penalty
Summary
The facility failed to properly dispose of expired medications, as observed during a survey. On one occasion, a medication cart contained an opened vial of Fiasp insulin labeled for a resident with diabetes mellitus and hyperglycemia. The vial was opened on August 14, 2024, and was still in use on September 19, 2024, despite the facility's policy stating that insulin should be discarded after 28 days. Interviews with an LPN and the Regional Director of Clinical Services confirmed that the insulin was expired and should have been disposed of. Additionally, the medication storage room contained a prefilled flu vaccine syringe with an expiration date of June 30, 2024. An LPN and the Director of Nursing acknowledged that the vaccine was expired and should have been discarded. The facility's policy, provided by the RDCS, indicated that outdated drugs should not be used and must be returned to the pharmacy or destroyed. These findings highlight the facility's failure to adhere to its medication storage and disposal policies.
Failure to Use Facial Hair Restraints in Kitchen
Penalty
Summary
The facility failed to ensure the use of facial hair restraints during kitchen operations, as observed during two separate kitchen inspections. On the initial kitchen tour, the Dietary Manager (DM) was seen moving through various kitchen areas, including food storage and preparation zones, with a visible mustache but without a hair restraint. This observation was repeated during a subsequent kitchen inspection, where the DM was preparing puree food items and checking food temperatures, again without a facial hair covering. During an interview, the DM acknowledged the availability of facial hair coverings but stated that staff were not required to wear them unless they had a full beard. The DM believed that a mustache did not necessitate a facial hair covering. The facility's policy, provided by the Administrator, indicated that mustaches should not extend more than half an inch from the corner of the mouth and that dietary staff must wear hair restraints, with facial coverings required if facial hair is long enough to potentially contaminate food.
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Illustrative
What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Oaktown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Freelandville Community Home | 7.2 mi | ★★★★★ | 26 | 0 |
| Aperion Care Vincennes | 13.4 mi | ★★★★★ | 24 | 0 |
| Bridgepointe Health Campus | 14.5 mi | ★★★★★ | 5 | 0 |
| Gentle Care Strategies | 15.4 mi | ★★★★★ | 0 | 0 |
| Waters Of Sullivan Nursing Facility, The | 15.9 mi | ★★★★★ | 10 | 0 |
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