Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Haven Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A severely cognitively impaired resident with dementia, a BIMS score of 3, and a documented elopement/wandering risk exited the building unsupervised after a CNA mistook him for a visitor and entered the door code. The resident, who wore a wanderguard, was later found standing beside a busy highway and resisted staff attempts to bring him back inside. Interviews and observations showed the door/wanderguard system was malfunctioning and multiple exits did not alarm or stay locked when residents approached.
A resident with severe cognitive impairment and a wanderguard was allowed to exit after a CNA mistook him for a visitor and did not recognize him as an elopement risk. Another CNA later found him outside near a busy roadway, and multiple staff members stated they were unsure how to identify residents at high risk for elopement.
A cognitively impaired resident with a BIMS score of 3 and a wanderguard bracelet exited the building unsupervised after a CNA did not recognize him as a resident and unlocked the door for him. The resident was later found standing beside a busy highway, and staff observed that multiple exit doors failed to alarm or remain locked when residents with wanderguards were near the doors. The facility had known the security system was malfunctioning, but staff were not re-educated and no added supervision was put in place.
Failure to Post Daily Nurse Staffing Information: Surveyors observed that the facility did not post updated staffing forms showing the actual hours worked by RN, LPN, and CNA staff responsible for resident care. A staffing form was displayed at the front desk, but the prior day's form was not available, and there was no binder with previous forms for public access. The Admin, DON, and Admin Asst confirmed they were unaware the staffing forms had to be updated and posted.
Pureed foods were prepared without approved recipes or measuring utensils, and staff used judgment-based amounts for ham, broth, eggs, bread, sugar, milk, and vanilla instead of following the facility’s puree food preparation policy. A dietary cook and the dietary manager both confirmed they did not follow approved recipes, and the Administrator confirmed they should have.
Food service safety standards were not maintained when a box of biscuits and a box of steak fingers were observed open to air in the freezer during an observation with the Dietary Manager. The Dietary Manager confirmed both items were open to air and should not have been.
Multiple new dietary staff members, including aides and cooks, were not trained in essential food safety procedures such as dishwashing, sanitizer checks, and following recipes for pureed foods. Required sanitation and food temperature logs were not completed or monitored, and personnel files lacked documentation of necessary training. The dietary manager acknowledged these oversights, which had the potential to impact all residents receiving meals from the kitchen.
Dietary staff did not follow approved recipes or measure ingredients when preparing pureed meals for residents on a puree diet, resulting in meals that did not meet facility policy for nutritional value and consistency. Both the cook and dietary manager confirmed that recipes were not followed during food preparation.
Surveyors found that the facility did not consistently monitor or log dishwashing, cooler, freezer, or food temperatures as required, and dietary staff were observed preparing food without proper hair restraints. These failures were confirmed by staff and violated facility policies, potentially affecting all residents receiving meals.
A resident with severe cognitive impairment and significant weight loss did not receive a physician-ordered dietary supplement of daily ice cream with lunch. Staff interviews and record reviews confirmed that the supplement was not provided as ordered, and the dietary card lacked the necessary information, resulting in the resident not receiving the prescribed intervention.
A facility failed to maintain a clean and homelike environment for a legally blind resident with intact cognition and multiple diagnoses, including Type 2 Diabetes Mellitus with Diabetic Retinopathy and Bipolar Disorder. After a hospital stay, the resident returned to find her belongings disorganized in a new room, making it difficult for her to locate items due to her blindness. The facility's administrator confirmed that staff should have assisted the resident in organizing her belongings to promote independence.
A facility failed to document a resident's smoking habit in their Care Plan, despite the resident being a safe smoker at the facility. The resident, with multiple diagnoses and moderately impaired cognition, had burns on their abdomen, which they denied causing. The DON confirmed the resident smoked at the facility, but no Care Plan was developed to address this.
A facility failed to maintain proper infection control during wound care for a resident with a Stage 3 pressure ulcer. The RN Treatment Nurse did not perform hand hygiene between glove changes, contrary to the facility's policy. The resident had multiple health issues, including cerebral palsy and malnutrition, requiring careful wound management. The DON confirmed the lapse in hand hygiene protocol.
A resident with severe cognitive impairment and physical limitations fell and sustained a hip fracture due to inadequate supervision and failure to follow care protocols. The resident required two-person assistance for bed mobility, but a CNA attempted to provide care alone, leading to the incident. Facility staff confirmed the oversight, acknowledging the CNA's failure to consult care instructions.
A facility failed to update a resident's care plan to include the need for two-person assistance for bed mobility and ADL care, despite the resident's high fall risk and severe cognitive impairment. The oversight was confirmed by the ADON, who noted that the necessary intervention was not documented in the care plan.
Failure to Supervise an Elopement-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and an environment free of accident hazards for a cognitively impaired resident who was identified as being at high risk for elopement and wandering. The resident had diagnoses including dementia, mild neurocognitive disorder with behavioral disturbance, cognitive communication deficit, major depressive disorder, anxiety disorder, and type 2 diabetes mellitus with hyperglycemia. A quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment. The resident was ambulatory, required supervision or touching assistance with transfers and ambulation, and wore a wanderguard/elopement alarm daily. The resident’s care plan identified him as an elopement risk and wanderer due to attempts to leave the facility unattended. Interventions included a wander alert bracelet on the right ankle, staff verification and skin inspection at the band location, and confirmation of signal operation. Staff interviews showed the resident frequently verbalized a desire to go home and had attempted to leave the facility on multiple occasions. The responsible party also reported prior incidents in which the resident was found outside the facility and escorted back inside. On the evening of the incident, a CNA observed the resident near an exit door and, believing he was a family member or visitor, entered the door code and allowed him to exit the building without accompanying him. The CNA stated she did not recognize him as a resident and was unaware he wore a wanderguard. Another CNA later found the resident standing next to a busy two-lane highway with a posted speed limit of 55 miles per hour, appearing to try to obtain a ride. Staff attempted to redirect him back into the facility, but he was agitated and resisted. Interviews and observations also showed the wanderguard/door alarm system was not functioning properly, with multiple exits failing to alarm or remain locked when residents wearing wanderguard devices were near the doors and staff entered the code. Facility administration confirmed they had been aware since an earlier contractor evaluation that the system required replacement, but no additional supervision measures had been put in place before the elopement.
Staff Failed to Recognize and Supervise an Elopement-Risk Resident
Penalty
Summary
Nursing staff were not competent to identify and supervise a resident at risk for elopement, and the facility failed to ensure staff could recognize residents who required elopement precautions. Resident #61 had a BIMS score of 3, indicating severe cognitive impairment, was ambulatory, required supervision or touching assistance with transfers and ambulation, and used a wanderguard/elopement alarm daily. The resident’s care plan identified him as an elopement risk due to attempts to leave the facility unattended, with interventions including a wander alert bracelet, staff verification and skin inspection at the band location, and confirmation of signal operation. On the evening of the incident, a CNA unlocked a facility door and allowed the resident to exit after believing he was a visitor and not recognizing him as a resident. The CNA stated she had previously seen the resident in common areas but thought he was a family member or visitor, and she was unaware that he wore a wanderguard bracelet. She also stated she was unsure how to determine whether a resident was at high risk for elopement. Another CNA who observed the resident outside near the roadway also did not recognize him as a resident and stated she was unsure how to determine if a resident was at high risk for elopement. The resident was found standing on the side of a busy two-lane highway in front of the facility, with a posted speed limit of 55 miles per hour. Staff reported that the resident was agitated and not easily redirected back into the building. Interviews with multiple CNAs and an LPN showed that staff were unsure how to identify residents at high risk for elopement, and the DON acknowledged that staff throughout the facility were unable to identify residents who were at risk for elopement even though they should have been.
Elopement Risk Not Recognized and Wanderguard System Failed
Penalty
Summary
The facility failed to administer its resources effectively to maintain the highest practicable physical, mental, and psychosocial well-being of a cognitively impaired resident who was identified as being at high risk for elopement and wandering. Resident #61 had a BIMS score of 3, was severely cognitively impaired, and wore a wanderguard bracelet. The resident was observed near Exit Door A, and a CNA who did not recognize the resident as a resident believed he was a family member or visitor. The CNA asked if he needed to exit, received a yes response, entered the door code, and allowed him to leave the building unsupervised. After the resident exited, he was found standing on the side of a busy two-lane highway in front of the facility with a posted speed limit of 55 miles per hour. Staff later observed that when the resident re-entered through another exit door, the alarm did not activate. The report also states that multiple exits, including Exit Door A, Exit Door B, and Exit Door C, failed to alarm and did not remain locked when residents wearing wanderguard devices were near the doors and staff entered the door code. The facility had been aware since 02/13/2026 that the wanderguard security system was malfunctioning. An outside contractor evaluated the system and was unable to repair it, recommending full replacement. The malfunction had the potential to affect multiple doors due to frequency interference, yet staff were not re-educated about the malfunctioning system, and no additional supervision measures were put in place at that time. The CNA involved stated she was unaware that the resident wore a wanderguard bracelet and was unsure how to identify residents at high risk for elopement.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information on a daily basis that included the total number and actual hours worked by RN, LPN, and CNA staff directly responsible for resident care per shift. The facility census was 93. On 04/13/2026 at 7:30 a.m., surveyors observed a Staffing Reporting Form dated 04/10/2026 displayed at the front desk, but there was no updated Actual Hours Worked for the date at the top of the form and no other form dated that day. On 04/14/2026 at 9:45 a.m., surveyors observed a Staffing Reporting Form dated 04/14/2026, but there was no posted form with actual hours worked from the previous day, 04/13/2026, and no binder available at the front desk with previous forms. Interviews on 04/15/2026 with the Admin and DON confirmed they were unaware that Actual Hours Worked on the Staffing Reporting Form were required to be updated and posted or kept where the public could access the forms. The Admin Asst also confirmed she was unaware that the updated staffing forms were required to be posted, and the previous days' forms had not been posted.
Failure to Follow Approved Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure pureed foods were prepared using methods that preserved nutritional value and followed approved recipes. Review of the facility policy titled Puree Food Preparation showed that pureed food was to be prepared to conserve nutritive value, palatable flavor, and attractive appearance, and that residents receiving puree diets should receive portions equivalent to those served on the regular or therapeutic diet ordered. The deficiency affected all 12 residents on a puree diet in a facility with a total census of 93. During observation of the dietary area, S12 Dietary Cook prepared pureed ham without following a recipe, stating she judged the amount of ham to use. She also poured chicken broth into the ham by using a glass and stated she was told to add broth until the ham started to thicken, then check the consistency with a spatula. The same staff member prepared egg mixture by pouring two boxes into a pan and placing it in the oven, stating she had been doing it long enough to know and did not need to measure. S13 Dietary Manager was also observed preparing pureed bread without a recipe or measuring utensils, removing an unmeasured amount of bread, adding an unmeasured amount of sugar, pouring an unmeasured amount of milk, and adding vanilla by pouring it into the cap. Both staff members confirmed they did not follow approved recipes, and the Administrator confirmed they should have followed approved recipes to prepare pureed foods.
Food Stored Open to Air in Freezer
Penalty
Summary
The facility failed to maintain a clean, sanitary environment and to ensure food was served in accordance with professional standards for food service safety. During an observation with the Dietary Manager, a box of biscuits and a box of steak fingers were found open to air in the freezer, and the Dietary Manager confirmed that both items were open to air and should not have been.
Lack of Dietary Staff Training and Competency in Food Safety Procedures
Penalty
Summary
The facility failed to ensure that dietary support personnel were competent to safely and effectively perform the functions of the food and nutrition service. Observations and interviews revealed that multiple dietary staff members, including dietary aides and cooks, had not received training on essential kitchen procedures such as properly washing and sanitizing dishes, setting up a 3-compartment sink, checking and recording dishwasher temperatures and sanitizer levels, or following recipes for preparing pureed foods. Staff members admitted to not performing or recording required sanitation checks and food temperature monitoring, and personnel files lacked documentation of training specific to these tasks. The dietary manager confirmed that food temperatures and sanitation logs were not being monitored or recorded as required by facility policy, and acknowledged that oversight of these processes had not occurred. High turnover in the kitchen resulted in most dietary staff being new and untrained, with the dietary manager responsible for training but failing to ensure staff competency. These deficiencies had the potential to affect all 89 residents who received meals prepared and served from the kitchen.
Failure to Follow Pureed Food Preparation Policy and Recipe
Penalty
Summary
The facility failed to ensure that pureed food was prepared according to established methods that preserve nutritional value and follow approved recipes. Observations revealed that the cook responsible for preparing pureed lemon broccoli did not measure ingredients or follow the facility's approved recipe, instead using unmeasured amounts of bread, broccoli, and apple juice. The cook also did not use the specified thickening agents or portion sizes outlined in the facility's policy and recipe. This resulted in meals for all seven residents on a pureed diet being prepared without adherence to nutritional guidelines or consistency standards. Interviews with the cook and dietary manager confirmed that dietary staff were not trained to follow recipes when preparing pureed food and that it was common practice not to use recipes. The dietary manager acknowledged that staff do not follow recipes, despite facility policy requiring them to do so. The deficiency affected all residents on a pureed diet, as their meals were not prepared in accordance with the facility's policy or approved recipes, potentially compromising the nutritional adequacy of their diets.
Failure to Maintain Sanitary Kitchen and Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not store or handle food in accordance with professional standards for food service safety. Surveyors observed that the dishwashing machine's temperature and sanitizer status were not monitored or logged daily, as confirmed by the Dietary Manager. Additionally, there was no documentation of daily cooler and freezer temperature checks for multiple days in November, and the Dietary Manager acknowledged that these checks were not being performed or recorded as required by facility policy. Food temperature logs were also incomplete, with several days lacking records for meal temperatures, which was confirmed by staff interviews. Further observations revealed that dietary staff did not consistently wear appropriate hair restraints while preparing food. Specifically, a dietary staff member with facial hair was seen preparing and handling food without a proper facial hair covering on multiple occasions and admitted to not wearing one, which was corroborated by the Dietary Manager. These failures were in direct violation of the facility's own policies regarding personal hygiene and food safety, and had the potential to affect all residents receiving meals from the kitchen.
Failure to Provide Ordered Dietary Supplement
Penalty
Summary
The facility failed to ensure that a physician's order for a dietary supplement was carried out for one resident. The resident, who had diagnoses including severe unspecified dementia with agitation, bipolar disorder, major depressive disorder, generalized muscle weakness, and dysphagia, was assessed as having severe cognitive impairment and was totally dependent on staff for eating. The resident experienced significant weight loss over a two-month period, and the care plan included a specific intervention to provide 4 ounces of ice cream daily with lunch as a nutritional supplement to address this issue. The physician's order for daily ice cream was documented in both the resident's care plan and physician orders. Despite these orders, observations and interviews revealed that the resident was not served ice cream with lunch as prescribed. The dietary card did not reflect the order for daily ice cream, and staff confirmed that the resident did not receive ice cream daily, but only on occasion. The Director of Nursing acknowledged that the order was not implemented and that the dietary card should have included the supplement. This failure resulted in the resident not receiving the prescribed nutritional intervention.
Failure to Maintain a Homelike Environment for a Legally Blind Resident
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident who was legally blind and had a history of Type 2 Diabetes Mellitus with Diabetic Retinopathy, Bipolar Disorder, Borderline Personality Disorder, and Pain Unspecified. The resident, who had intact cognition, was admitted to the facility and required assistance with activities of daily living due to visual deficits. Upon returning from a hospital stay, the resident found that her personal belongings had been disorganized and packed into boxes in a new room, making it difficult for her to locate her items due to her blindness. The resident expressed concern about the room change and the disarray of her belongings, which were not arranged to promote her independence as per her care plan. During an observation and interview, it was noted that the resident's room was cluttered with boxes containing clothes and personal items, and her nightstand drawers were in disarray. The resident confirmed that she struggled to find her belongings and that no staff had offered assistance in organizing her new room. The facility's administrator acknowledged the situation and confirmed that staff should have helped the resident unpack and arrange her belongings following the room change. This failure to provide a neat and well-kept environment compromised the resident's ability to navigate her space independently.
Failure to Document Smoking in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a Person-Centered Care Plan for a resident, specifically regarding their smoking habits and necessary nursing interventions. The resident, who was admitted with multiple diagnoses including Multiple Sclerosis, Paraplegia, Anxiety Disorder, Personality Disorder, Pressure Ulcer, Bipolar Disorder, and Insomnia, had a BIMS score indicating moderately impaired cognition. The resident required extensive assistance for bed mobility and toilet use, was dependent for transfers, and was independent with eating. A progress note revealed that the resident had blisters on their abdomen, diagnosed as burns by a nurse practitioner, although the resident claimed not to have burned themselves and denied having a lighter. During an interview, the resident stated they were a safe smoker at the facility. However, a review of the resident's Care Plan showed no documentation of their smoking habit. The Director of Nursing confirmed that the resident smoked while at the facility and acknowledged that a Care Plan addressing this had not been developed, although it should have been.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during wound care for a resident. The facility's policy on wound care, effective from September 1, 2023, outlines specific steps for hand hygiene, including washing hands before and after glove use. However, during an observation on February 5, 2025, the RN Treatment Nurse did not adhere to these guidelines while providing wound care to a resident with a Stage 3 pressure ulcer on the left heel. The nurse removed a soiled dressing, cleansed the wound, and applied medications without washing or sanitizing hands between glove changes. The resident involved had multiple diagnoses, including cerebral palsy, malnutrition, and pressure-induced deep tissue damage, necessitating careful wound management. Despite the facility's policy requiring hand hygiene to prevent nosocomial infections, the nurse confirmed in an interview that she did not perform hand hygiene at any point during the procedure. The Director of Nursing also confirmed that hand hygiene should have been completed before and after glove use, indicating a lapse in following established infection control protocols.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who was at high risk for falls due to severe cognitive impairment and physical limitations. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, required substantial assistance for activities of daily living, including bed mobility. Despite these needs, the resident was left in the care of a single CNA who did not adhere to the facility's policy requiring two-person assistance for such tasks. On the day of the incident, the CNA was responsible for giving the resident a bed bath but failed to consult the overhead bed signage or the kiosk for the necessary care instructions. As a result, the CNA attempted to turn the resident alone, leading to the resident rolling out of bed and sustaining a closed right hip fracture. The CNA admitted to not checking the required care instructions, which were clearly documented and accessible. Interviews with facility staff confirmed that the resident's care plan and overhead signage indicated the need for two-person assistance, which was not followed. The CNA supervisor and other staff members acknowledged that the CNA had been trained on the importance of following these instructions. The incident resulted in actual harm to the resident, highlighting a significant lapse in adherence to established care protocols.
Failure to Update Care Plan for Two-Person Assistance
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised to reflect the need for extensive assistance with two-person physical assistance for turning, repositioning, and bed mobility during ADL care. The resident, who was at high risk for falls due to limited mobility and a history of a cerebrovascular accident (CVA) affecting the right side, experienced a fall with major injury. Despite the resident's need for substantial assistance in various activities, the care plan did not include the necessary intervention for two-person assistance, which was identified as a requirement but not documented. The resident's medical record indicated severe cognitive impairment and functional limitations in range of motion, necessitating maximal assistance for daily activities. The facility's policy required that each resident's care plan be updated following a fall, but the intervention for two-person assistance was not included in the care plan. This oversight was confirmed during an interview with the Assistant Director of Nursing (ADON), who acknowledged that the resident's care plan should have been updated to include the necessary assistance for bed mobility and ADL care.
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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.
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Nursing homes near Center Point
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Health Care Facility | 10.4 mi | ★★★★★ | 7 | 0 |
| Colonial Nursing And Rehabilitation Center | 11.5 mi | ★★★★★ | 10 | 0 |
| Riviere De Soleil Community Care Center | 13.4 mi | ★★★★★ | 5 | 0 |
| Legacy Nursing At St. Christina | 13.5 mi | ★★★★★ | 21 | 0 |
| Hilltop Nursing & Rehabilitation Center | 13.6 mi | ★★★★★ | 13 | 0 |
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