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 Oak Forest Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care: one was injured after being rolled out of bed by a single staff member despite requiring two-person assist for bed mobility, resulting in multiple fractures and a hematoma; another resident, identified as a smoker, did not receive timely quarterly smoking assessments as required by facility policy, though was observed to smoke safely and independently.
Two residents with nicotine dependence and hypertension were observed smoking independently without any corresponding care plan interventions or goals addressing their smoking behaviors. Staff interviews confirmed that these residents should have been care planned for smoking, but this was not done.
A resident with a history of stroke and hypertension, dependent on staff for ADLs and not ambulatory, was found to have overgrown, thick, and yellow toenails, including an ingrown toenail causing discomfort and inability to wear shoes or socks. Despite being on the list for podiatry, the resident was not seen by the podiatrist since admission, and staff were unaware of the missed visit, resulting in a lack of appropriate foot care.
Two residents' narcotic medications, totaling 75 doses of Oxycodone 5 mg, were unaccounted for after being left unsecured following discharge and death. Nursing staff placed the medications in a pharmacy tote and an unlocked desk drawer, both accessible to multiple staff members, without ensuring double-lock security. The medications were missing when the pharmacy and facility later attempted to reconcile them.
Unused narcotic medications for two residents were not stored in double-locked, permanently affixed compartments as required. Instead, the medications were placed in a pharmacy tote and an unlocked desk drawer in an office accessible to multiple staff. As a result, significant quantities of Oxycodone were found missing when the medications were to be returned to the pharmacy, with staff interviews confirming lapses in following proper storage procedures.
Two residents who were assessed as safe, independent smokers and had intact cognition were not allowed to smoke outside of designated hours due to a facility policy limiting smoking times. Both residents expressed dissatisfaction with the restriction, and staff confirmed that multiple complaints had been made about the inability to smoke after certain hours. Facility leadership stated the policy was a department head decision and were unaware of resident complaints.
Two residents with chronic pain and cognitive impairment were not protected from the misappropriation of their prescribed Oxycodone when 84 tablets and related documentation went missing from a medication cart. Despite required narcotic counts and no reported pain issues or suspicious behavior, the loss was only discovered during an audit, and staff were unable to account for the missing medications.
A resident with significant physical limitations and a need for staff assistance with ADLs was not provided with regular facial shaving, despite a care plan specifying this need and the resident's stated preference for a clean-shaven face. Staff interviews confirmed awareness of the resident's grooming preferences, but the lapse in care was not explained by the assigned nurse aide, nurse, or facility leadership.
A resident with an indwelling suprapubic catheter, who was fully dependent on staff for care, was observed on multiple occasions with their urinary catheter drainage bag resting on the floor while the bed was in a low position. Staff interviews confirmed knowledge of the requirement to keep catheter bags off the floor, but the deficiency persisted over several days.
The facility failed to accurately code the MDS assessments for two residents using CPAP machines. Despite having care plans and physician's orders for CPAP use, the MDS assessments did not reflect this, as the MDS nurse was unaware of the need to code CPAP usage as non-invasive mechanical ventilation. The administrator expected accurate coding by the MDS nurses.
An agency nurse in a LTC facility administered the wrong medications to a resident, leading to a significant medication error. The resident, with a history of bipolar disorder and chronic kidney disease, received medications intended for another resident, including psychotropic and anticonvulsant drugs. The error was identified by the nurse, who reported it immediately. Despite monitoring and interventions, the resident's condition worsened, resulting in hospitalization for acute kidney injury and other complications.
A medication administration error occurred when an agency nurse misidentified a resident and administered another resident's medications. The resident, who was moderately cognitively impaired, received medications not prescribed to them, including metformin and aspirin. The error was realized shortly after, and the resident was monitored for adverse effects, with no immediate distress observed.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, limited mobility, and contractures was not provided care in accordance with her care plan, which required two-person assistance for bed mobility and use of a mechanical lift for transfers. During incontinent care, a nursing assistant attempted to reposition the resident alone, resulting in the resident rolling off the bed and sustaining significant injuries, including a fractured clavicle, a rib fracture, and a large scalp hematoma. The resident was on blood thinning medication due to a history of pulmonary embolism, further complicating her condition. The nursing assistant admitted to being aware of the two-person assist requirement but did not request help, and the posted note indicating this requirement was not noticed by the assistant at the time of the incident. Additionally, the facility failed to conduct timely smoking assessments for another resident with a diagnosis of tobacco use. The resident's care plan identified a risk for injury related to smoking, and facility policy required quarterly smoking assessments. However, there was a lapse of several months between assessments, exceeding the expected quarterly interval. Despite this, the resident was observed to smoke independently and safely during the survey, with no evidence of burns or injury at the time of observation. Both deficiencies were identified through observation, record review, and staff interviews. The first involved a failure to follow established care protocols for a resident with significant physical and cognitive impairments, resulting in a serious fall and injury. The second involved a failure to adhere to the facility's policy for regular smoking assessments, which are intended to minimize the risk of smoking-related injuries.
Failure to Develop and Implement Smoking Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plan interventions for two residents with nicotine dependence who were observed smoking independently. Both residents had documented diagnoses including hypertension and nicotine dependence, and their most recent smoking assessments were completed. However, review of their care plans revealed no goals or interventions addressing their smoking behaviors. Despite being cognitively intact, one resident required limited assistance with activities of daily living (ADL), while the other required extensive assistance. Both residents reported smoking since admission or shortly thereafter. Interviews with the MDS Coordinators, Director of Nursing (DON), and Administrator confirmed that they were unaware these residents had not been care planned for smoking. The staff acknowledged that all residents who smoke are expected to have care plans with specific goals and interventions, but this was not done for the two residents in question. The deficiency was identified through record review, observation, and staff interviews.
Failure to Coordinate Podiatry Care for Dependent Resident
Penalty
Summary
A resident with a history of stroke and hypertension, who was dependent on staff for activities of daily living and not ambulatory, was observed to have overgrown, thick, and yellow toenails, including an ingrown toenail that caused discomfort and prevented her from wearing shoes or socks. The resident reported that a nurse aide had trimmed some of her smaller toenails a few days prior, but she had not been seen by a podiatrist, despite her ongoing discomfort and request for podiatry care. Interviews with nursing staff and the Director of Nursing (DON) revealed that the resident was supposed to be seen by the facility's podiatrist during a recent visit but was not, and there was uncertainty as to why she had been missed. The DON confirmed that the resident had not been assessed by podiatry since admission, despite being on the list for the previous podiatry visit. The facility expected residents' toenails to remain trimmed and for podiatry to be consulted if issues arose, but this did not occur for the resident in question.
Failure to Secure and Account for Narcotic Medications After Resident Discharge or Death
Penalty
Summary
The facility failed to maintain effective systems and safeguards to prevent drug diversion, specifically regarding the handling and security of narcotic medications for two residents. In the first case, a resident with diabetes and diabetic neuropathy, who was cognitively intact and receiving opioid medications, was discharged to the hospital. After discharge, 45 doses of Oxycodone 5 mg prescribed to the resident were found to be missing. Nursing staff reported counting and placing the medication in a pharmacy tote, sealing it, and leaving it in the Unit Manager's office for pharmacy pickup. However, the medication was not present when the pharmacy received the tote, despite the correct documentation and seals being in place. The tote had been left in an office accessible to multiple staff members, and it was unclear how long it remained there before being sent to the pharmacy. In the second case, another cognitively intact resident with lung cancer, who was also receiving opioid medications, died in the facility. After the resident's death, a medication card containing 30 doses of Oxycodone 5 mg was placed in an unlocked desk drawer in the Unit Manager's office by the night shift supervisor. The office was locked, but several staff members had access to it. The medication was not secured under double lock as required, and the doses were later found to be missing. The narcotic count form for the medication was discovered in the unlocked drawer, but the medication itself was unaccounted for. Interviews with nursing staff and the pharmacist confirmed that the medications were not properly secured and that staff were unaware of the requirement to keep narcotic medications double locked until returned to the pharmacy. The facility's failure to ensure the security of these medications resulted in a total of 75 doses of Oxycodone being unaccounted for, with the medications left in areas accessible to multiple staff members and not properly safeguarded against diversion.
Failure to Secure and Store Narcotics Results in Missing Medications
Penalty
Summary
The facility failed to store unused narcotic medications in accordance with its own policy and accepted professional standards, resulting in the loss of controlled substances prescribed to two residents. For one resident, a physician had ordered Oxycodone 5 mg every four hours as needed for pain, and after the resident was discharged to the hospital, the remaining doses were counted by two nurses and placed in a pharmacy tote with a numbered zip lock tag. This tote was then stored in the Unit Manager's office, which was not always locked and accessible to several staff members. The exact duration the tote remained in the office before being sent to the pharmacy was unknown, and when the pharmacy received the tote, the medication was missing, though the seals were intact. For another resident, who had a physician's order for Oxycodone 5 mg three times daily for pain, the remaining medication was placed by the night shift supervisor in an unlocked desk drawer in the same office. The office was sometimes locked, but multiple staff had keys, and the medication was not secured in a double-locked compartment as required. During an investigation into the missing narcotics for the first resident, it was discovered that the medication for the second resident was also missing, with only the narcotic count form found in the unlocked drawer. Interviews with nursing staff and the DON confirmed that the process for storing and returning narcotics was not consistently followed, and staff were unaware that medications should not be left in unsecured locations. The facility's policy required all narcotic medications to be stored under double lock in a designated cabinet or safe, but this was not adhered to, resulting in the loss of a significant number of controlled medication doses for both residents.
Failure to Support Resident Choice for Independent Smoking
Penalty
Summary
The facility failed to honor the rights of residents to self-determination and choice by restricting the smoking times for residents who had been assessed as safe, independent smokers. Two residents with intact cognition and a history of tobacco use were care planned and assessed as able to smoke independently and safely. Despite this, the facility implemented a policy limiting smoking in the designated area to between 8:00 AM and 8:00 PM, as indicated by posted signage and confirmed through staff and resident interviews. Both residents expressed dissatisfaction with the imposed smoking schedule, stating their preference to smoke outside of the designated hours, including late evenings and early mornings. Staff interviews confirmed that multiple residents had complained about the restricted smoking times, and that these concerns had been communicated to nursing staff. The decision to restrict smoking hours was made by department heads, and facility leadership reported being unaware of resident complaints regarding the policy.
Failure to Safeguard Residents' Narcotic Medications
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed narcotic medications, specifically Oxycodone. Both residents had chronic pain and were moderately cognitively impaired, with physician orders for Oxycodone—one as needed and one scheduled via feeding tube. During a routine audit, it was discovered that two cards of Oxycodone, totaling 84 tablets, and the second page of the narcotic count sheet were missing from a medication administration cart assigned to a specific hall. The discrepancy was identified during a narcotic process audit by the DON, who found that the medications and documentation were not present as required. The investigation revealed that the last nurse assigned to the cart did not notice any discrepancies during the shift change narcotic count, which was conducted and signed off by both the outgoing and incoming nurses. No pain issues were reported for the residents during the relevant shifts, and the medication administration records indicated that one resident did not require PRN Oxycodone, while the other received her scheduled dose. Despite the required procedures for narcotic counts and documentation at each shift change, the missing medications were not detected until the audit, and no staff reported any issues or suspicious behavior prior to the discovery. Interviews with nursing staff, the pharmacy consultant, and the medical director confirmed that the narcotic count was believed to be correct at the time of shift changes, and no one could account for the missing medications. The facility's process required two nurses to complete narcotic counts at each shift change and to report any discrepancies immediately, but the loss of the narcotics and documentation was not identified until after the fact. The investigation was unable to determine how the medications were removed or by whom, resulting in a failure to safeguard the residents' property as required.
Failure to Provide Grooming Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, muscle weakness, left side hemiplegia, post-polio syndrome, and dysphagia, who was cognitively intact but required extensive assistance with activities of daily living (ADLs), was not provided with appropriate grooming care. The resident's care plan specified a need for total assistance with bathing and staff assistance with grooming and personal hygiene, including shaving facial hair. During an observation, the resident was found to have several chin hairs approximately one inch in length and expressed a preference for a clean-shaven face, stating she often had to request staff assistance for shaving. Interviews with staff revealed that the nurse aide assigned to the resident was aware of the resident's grooming preferences and confirmed that the resident rarely refused care. However, the aide was unsure why the resident's face had not been shaved. The nurse assigned to the resident was not aware of the facial hair and did not recall any resistance to personal care from the resident. Both the administrator and the DON were also unaware of the reason for the lapse in grooming and stated that residents were expected to be kept clean and shaved as preferred.
Catheter Drainage Bag Found Resting on Floor for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of hydronephrosis, urogenital implants, and neuromuscular dysfunction of the bladder, who was dependent on staff for all activities of daily living and had an indwelling suprapubic catheter, was observed multiple times with their urinary catheter drainage bag resting on the floor. The resident's care plan included interventions to keep the urinary collection bag below the level of the bladder, but did not specify that the bag should not touch the floor. During three separate observations over consecutive days, the catheter bag was seen hanging from the bedframe with the entire bottom of the bag in contact with the floor while the bed was in a low position. Staff interviews confirmed awareness of the requirement to keep catheter bags off the floor to prevent infection. A nurse aide reported having noticed the bag on the floor several times and repositioning it, while the DON stated that staff had been educated on this practice and that hooks were available for proper placement. The unit manager also acknowledged the expectation that the drainage bag should not touch the floor and described a temporary measure taken to prevent contact with the floor.
Inaccurate MDS Coding for CPAP Usage
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in relation to the use of continuous positive airway pressure (CPAP) machines. Resident #1, who was admitted with diagnoses including obstructive sleep apnea and acute respiratory failure with hypoxia, had a care plan indicating the use of a CPAP machine. Despite having an active physician's order for CPAP use and documented usage with occasional refusals, the Quarterly MDS assessment did not reflect the use of a CPAP machine. During an interview, MDS Nurse #1 admitted to not being aware of the need to code the CPAP usage as non-invasive mechanical ventilation. Similarly, Resident #2, admitted with obstructive sleep apnea, also had a care plan and physician's order for CPAP use. The resident's Significant Change MDS assessment failed to code the use of the CPAP machine, despite documented compliance with the physician's order. MDS Nurse #1 again acknowledged the oversight in coding, indicating a lack of awareness regarding the requirement to code CPAP usage as non-invasive mechanical ventilation. The facility's administrator expected the MDS nurses to ensure accurate coding of the residents' MDS assessments.
Significant Medication Error Due to Agency Nurse's Mistake
Penalty
Summary
The facility failed to protect a resident from a significant medication error when an agency nurse, Nurse #1, administered the wrong medications to Resident #1. On the morning of the incident, Nurse #1 gave Resident #1 his prescribed medications and later mistakenly administered medications intended for another resident, Resident #2, to Resident #1. The wrongly administered medications included several psychotropic and anticonvulsant drugs, which were not prescribed for Resident #1. Nurse #1 realized the error after returning to her medication cart and immediately reported it to the Unit Manager and the Nurse Practitioner (NP). Following the medication error, Resident #1 was monitored for any adverse effects. Initially, his vital signs were within normal limits, but later in the day, his blood pressure dropped, prompting the NP to order intravenous fluids. Despite these interventions, Resident #1's condition worsened, and he became lethargic and unresponsive. By the following day, his altered mental status necessitated a transfer to the Emergency Department for further evaluation. In the hospital, Resident #1 was diagnosed with acute kidney injury, potentially due to medication side effects, and was treated with intravenous fluids and antibiotics. Resident #1 had a medical history that included bipolar disorder, dementia, anxiety disorder, heart failure, and chronic kidney disease, which may have contributed to his vulnerability to the medication error. The facility's failure to ensure proper medication administration procedures, particularly by an agency nurse unfamiliar with the residents, led to this significant medication error. The incident highlights the importance of adhering to medication administration protocols to prevent such errors, especially when agency staff are involved.
Removal Plan
- The Director of Nursing completed a 100% audit on all current alert and oriented residents with brief interviews for mental status of 13 or greater to ensure there were no issues with medication administration.
- A body audit was completed by the DON, Assistant DON, and Unit Managers on all non-verbal, non-alert residents with BIMS of 12 or lower to ensure there were no issues related to medication administration.
- The DON, ADON, unit managers, and Staff Development Coordinator began interviewing nurses and medication aids during med pass observations to check if they had performed medication errors.
- The DON reviewed all incident reports to identify any recent medication errors.
- The Staff Development Clinician began in-servicing all Registered Nurses, Licensed Practical Nurses, and medication aides, including agency staff, on Preventing Medication Error policy.
- The Director of Nursing ensured that any staff who did not complete the in-service training would not be allowed to work until the training was completed.
- The DON, Assistant DON, unit managers, and SDC will monitor medication administration passes using the Quality Assurance monitoring tool Med Pass Audit.
- Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate.
- The decision was made to initiate this into the QA process and to review it in QA.
Medication Administration Error Due to Resident Misidentification
Penalty
Summary
The facility failed to protect a resident from non-significant medication errors, as evidenced by an incident involving a medication administration error. A resident, who was moderately cognitively impaired and had multiple diagnoses including bipolar disorder, dementia, anxiety disorder, heart failure, and chronic kidney disease, was mistakenly given another resident's medications. This error occurred when an agency nurse, who was on her second day at the facility, addressed the resident by the wrong name, and the resident confirmed the incorrect identity. The nurse administered medications intended for another resident, including metformin, aspirin, levocarnitine, and baclofen, to the wrong resident. Upon realizing the mistake, the nurse immediately notified the Unit Manager, the Nurse Practitioner, and the resident's family. The resident was assessed and found to be stable, with vital signs within normal limits, and was monitored for any adverse effects such as hypotension and bradycardia. Interviews with the involved staff, including the nurse, Unit Manager, and Nurse Practitioner, confirmed the sequence of events and the immediate actions taken following the error. The Medical Director was also informed and did not anticipate any negative outcomes from the non-significant medications administered. The incident highlighted a lapse in the medication administration process, specifically in verifying the correct resident before administering medications.
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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 Winston Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mill Creek Center For Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 1 | 0 |
| Brookridge Retirement Community | 3.8 mi | ★★★★★ | 1 | 0 |
| Salemtowne | 4.7 mi | ★★★★★ | 2 | 0 |
| Arbor Acres United Methodist Retirement Community | 6.2 mi | ★★★★★ | 2 | 0 |
| Trinity Glen | 6.4 mi | ★★★★★ | 2 | 0 |
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