Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Oaks during CMS and state inspections, most recent first.
Surveyors found that the facility failed to conduct and document required quarterly care plan meetings, resulting in three residents and/or their responsible parties not being invited to participate in the development and implementation of person-centered care plans. One resident with multiple medical conditions and intact cognition had no evidence of any quarterly care plan meetings before death in the hospital. Another resident with severe cognitive impairment and complex diagnoses had not had a care plan meeting since an earlier documented session, and a third resident with moderate cognitive impairment and multiple chronic conditions also had no quarterly care plan meetings scheduled. The SSD acknowledged she had not scheduled these meetings, and the DON confirmed that the facility did not conduct them.
The facility failed to follow its abuse and injury reporting policy by not immediately informing the Administrator of an unwitnessed fall that resulted in serious bodily injury. A resident with multiple medical conditions, intact cognition, and no recent falls was found by an LPN lying face down on the floor, unresponsive, with a hematoma and laceration to the head and blood on the floor, and was sent to the ER where the resident later died. The DON was notified around shift change and then contacted the Corporate Administrator later that morning, but only reported that the resident had a fall, omitting that it was unwitnessed and involved serious head trauma, contrary to the requirement to report such events within two hours with full details.
A resident with a history of severe medical conditions and a Stage 4 pressure ulcer developed six unidentified pressure ulcers on the feet, which were not reported or treated by the wound care nurses or floor nurse. The resident's feet also showed signs of neglect, with a buildup of peeling skin. The Director of Operations and DON were informed of these findings.
A resident with moderate cognitive impairment and identified as an unsafe smoker was repeatedly found smoking in their room and improperly disposing of cigarette ashes, contrary to the facility's smoking policy. Despite the care plan noting the need for supervision, the resident was observed smoking without a smoking apron and without staff supervision, leading to a deficiency in maintaining a safe environment.
A facility exceeded the acceptable medication error rate, reaching 6.25%. An LPN failed to administer Citracal-D3 to a resident due to unavailability and administered an incorrect dosage of Lisinopril, giving 20mg instead of the prescribed 10mg. The DON confirmed the errors and acknowledged the need for adherence to physician orders.
The facility failed to maintain personal hygiene for two residents. A resident with severe vascular dementia had a dirty hand mitt and untrimmed fingernails, while another with Parkinson's disease had long, jagged toenails. The DON confirmed the deficiencies, indicating a lapse in adhering to the facility's Nail Management Policy.
Failure to Involve Residents and Representatives in Quarterly Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents and/or their responsible parties were allowed to participate in the development and implementation of person-centered plans of care by not scheduling required quarterly care plan meetings. For Resident #1, who was admitted with multiple diagnoses including unspecified atrial fibrillation, right rib fractures, type 2 diabetes mellitus, stroke, hypertension, and age-related osteoporosis, record review showed no documented evidence of any quarterly care plan meetings prior to the resident’s death in the hospital. The Quarterly MDS for this resident showed a BIMS score of 13, indicating no cognitive impairment, yet there was no documentation that the resident had been invited to or participated in quarterly care plan meetings. For Resident #2, admitted with conditions including conversion disorder with seizures or convulsions, severe unspecified dementia with behavioral disturbance, vascular dementia with agitation, malignant neoplasm of the prostate, acute kidney failure, depressive episodes, repeated falls, and other specified mental disorders, the Quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment. The SSD stated she was responsible for scheduling quarterly care plan meetings but had not scheduled any for this resident, and the last care plan meeting on record was several months earlier. For Resident #3, admitted with Bell’s palsy, chronic pain syndrome, paroxysmal atrial fibrillation, GERD, chronic diastolic heart failure, major depressive disorder, trigeminal neuralgia, generalized anxiety disorder, metabolic encephalopathy, and Parkinson’s disease, the Quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. The SSD similarly confirmed she had not scheduled any quarterly care plan meetings for this resident. In all three cases, the DON confirmed the facility failed to conduct the required care plan meetings.
Failure to Timely Report Unwitnessed Fall With Serious Head Injury
Penalty
Summary
The facility failed to ensure that an allegation of an injury of unknown source with serious bodily injury was reported immediately, or within two hours, to the Administrator as required by its abuse, neglect, exploitation, or misappropriation reporting policy. The policy specified that all suspected abuse, neglect, exploitation, misappropriation, or injuries of unknown source must be reported immediately to the Administrator and appropriate authorities, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. For one resident, the Director of Nursing (DON) was notified around 7:00 a.m. by an LPN that the resident had been found on the floor unresponsive with a hematoma to the right side of the head and a laceration to the back of the head, but the DON did not convey the seriousness and unwitnessed nature of the incident when notifying the Corporate Administrator. The resident involved had been admitted with diagnoses including unspecified atrial fibrillation, right-sided rib fractures, type 2 diabetes mellitus without complications, stroke, hypertension, and age-related osteoporosis without current pathological fracture. A recent Quarterly MDS showed a BIMS score of 13 (no cognitive impairment), supervision or touching assistance needed for bed mobility, transfers, and toileting, partial/moderate assistance for bathing, no functional ROM limitations, and no recent falls. On the morning of the incident, the LPN found the resident lying face down on the floor, unresponsive, with visible head injuries and blood on the floor, and sent the resident to the emergency room, where the resident later expired. The DON notified the Corporate Administrator at 9:15 a.m. but only reported that the resident had a fall, omitting that it was unwitnessed and resulted in serious bodily injury, and the Corporate Administrator confirmed he should have been notified immediately of the unwitnessed fall with serious bodily injury.
Failure to Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, consistent with professional standards of practice. The resident, who was admitted with a history of transient ischemic attack, cerebral infarction, severe vascular dementia, primary open-angle glaucoma, cerebral palsy, and a Stage 4 pressure ulcer on the right hip, developed six unidentified pressure ulcers on the feet. During a wound care session, deep tissue injuries were observed on both feet, including the great toe, heel, and ankle, which had not been previously identified or reported by the wound care nurses or the floor nurse. Additionally, the resident's feet showed signs of neglect, with a thick, flaky, and crusty buildup of peeling skin between the toes, indicating a lack of proper hygiene and care. The wound care nurses and the floor nurse confirmed their unawareness of the new pressure ulcers, and the Director of Operations and Director of Nursing were informed of these findings. This lack of awareness and reporting contributed to the deficiency in providing adequate pressure ulcer care and prevention for the resident.
Failure to Supervise Unsafe Smoker
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as an unsafe smoker. The resident, who had a history of type 2 diabetes mellitus, cellulitis, alcohol dependence, noncompliance with medical treatment, repeated falls, hypertension, and nicotine dependence, was assessed to have moderate cognitive impairment. Despite being identified as an unsafe smoker, the resident was found smoking in his room on multiple occasions, which was against the facility's smoking policy. The care plan noted the resident's potential for injury related to smoking, yet incidents of smoking in the room were recorded on several dates, and a care plan meeting was held with the resident's sister and ombudsman to address these issues. Observations revealed that the resident was not wearing a smoking apron and was placing cigarette ashes and butts in a garbage can with a plastic liner, which posed a fire hazard. No staff were present to monitor the resident during these times, despite the facility's policy requiring direct supervision for residents with restricted smoking privileges. Interviews with staff confirmed the resident's unsafe smoking behavior and the facility's failure to adhere to its smoking policy, which contributed to the deficiency in providing a safe environment and adequate supervision to prevent accidents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 6.25% error rate. During a medication pass observation, two errors were identified out of 32 opportunities. The first error involved the non-administration of Citracal-D3, a calcium citrate supplement, to a resident as per the physician's order for daily administration at 8:00 a.m. The LPN responsible confirmed that the medication was not administered because it was unavailable. The second error involved the administration of an incorrect dosage of Lisinopril, an angiotensin-converting enzyme inhibitor. The resident was given a 20mg tablet instead of the prescribed 10mg. The LPN acknowledged the mistake and confirmed the correct order was for a 10mg daily dose. The Director of Nursing was informed of these errors and confirmed that medications should be administered as ordered.
Failure to Maintain Personal Hygiene for Residents
Penalty
Summary
The facility failed to provide necessary services for maintaining good personal hygiene for two residents who were unable to perform activities of daily living. Resident #3, who had a history of transient ischemic attack, severe vascular dementia, and a Stage 4 pressure ulcer, was observed with a dirty hand mitt that had a large, dried reddish-brown stain. Despite being notified, the LPN reapplied the dirty mitt. Later, the DON confirmed the mitt was unclean, and upon removal, the resident's hand was found to be crusty and dirty, with jagged and untrimmed fingernails. Resident #37, diagnosed with Parkinson's disease and vascular dementia, was observed with long and jagged toenails. The DON confirmed the need for trimming the toenails. Both cases highlight the facility's failure to adhere to its Nail Management Policy and Procedure, which emphasizes regular care to promote cleanliness and prevent infection and injury.
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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 Monroe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mary Goss Nursing Home | 2.4 mi | ★★★★★ | 12 | 0 |
| Landmark Nursing & Rehabilitation Ctr Of West Mon | 2.6 mi | ★★★★★ | 8 | 0 |
| St Joseph Skilled Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 11 | 0 |
| Ridgecrest Community Care Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Delta Grande Skilled Nursing And Rehabilitation | 3.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.