Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Oakbrook Health And Rehabilitation Center during CMS and state inspections, most recent first.
Inadequate RN coverage occurred when the facility had a census above 60 residents on multiple days and did not provide the required RN coverage for 14 days across three months. The facility policy required sufficient nursing staff and an RN for at least 8 consecutive hours daily, but interviews confirmed staffing shortages, with the DON and MDS Coordinator sometimes used to cover RN shifts and agency staffing still failing to ensure coverage.
Expired and unlabeled medications were found in multiple medication carts and a medication room, including an expired Buspirone card, inhalers without prescription or open-date labels, open Artificial Tears and Anero Ellipta, expired glucose control solutions, and expired blood glucose test strips. An Albuterol inhaler was also found with the meter reading 0 puffs. The UM and DON stated carts and medication rooms were being audited by nursing and pharmacy staff on a weekly and monthly basis.
Posted and master menus did not match the meals actually served to residents during lunch service. A CDM changed menu items based on resident feedback but did not update the master menu, and a relief cook prepared the meal from the master menu instead of the posted menu or meal tickets. Residents received different items than listed, and the DON was not aware of at least one menu change.
Infection Control: Improper Glove Use An RN was observed exiting a resident's room carrying a closed plastic bag with soiled gloves still on, then entering the code to the soiled utility room while wearing the same gloves. The RN confirmed the glove use in the hallway and into the soiled utility room and stated the bag contained a soiled brief. The facility policy states gloves are to be discarded after each use and hand hygiene performed immediately after removal.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
A resident with a history of malignant neoplasm and diabetes did not receive prescribed tube feeding, leading to dangerously low blood sugar levels. The resident was on a regimen of Osmolite 1.5, but observations revealed water flushes were administered instead. Despite insulin administration, the resident's blood sugar dropped, requiring Glucagon and glucose gel. The issue was traced to incorrect pump settings, which were not adjusted, resulting in inadequate nutritional intake.
A resident with a history of right knee pain and other medical conditions did not receive adequate pain management due to a lack of pain medication orders and monitoring. Despite the resident's reports of severe pain and a nurse practitioner's attempt to order Tylenol, a system glitch prevented the order from being processed, and there was no follow-up to ensure the resident's pain was managed. The resident was observed in significant pain, and the facility's Director of Nurses acknowledged the issue with the electronic system and the absence of pain monitoring.
The facility failed to ensure proper food storage and labeling, affecting all 85 residents. Observations revealed open and undated food items in the refrigerator and dry storage, with some items on the floor. Staff interviews confirmed non-compliance with facility policies requiring labeled and dated food storage. This deficiency could impact resident health and safety.
The facility failed to properly store and label medications in two medication rooms and two medication carts. Inspections revealed opened and undated vials of Tubersol, improperly stored insulin syringes, and expired Urinalysis Reagent Strips. Controlled substances were not securely affixed as required. These deficiencies were confirmed by nursing staff and acknowledged by the DON.
A resident was found with Fluticasone spray at the bedside without a physician's order for self-administration, contrary to the facility's policy. The LPN confirmed the absence of such an order, and the DON emphasized that medications should not be left at the bedside, especially with wandering residents present.
A resident with Type 2 diabetes received insulin without the pen being primed, contrary to facility policy. An LPN administered 15 units of insulin after a blood sugar reading of 413, without following the required procedure of priming the pen. The DON confirmed that priming is part of the medication administration protocol.
The facility failed to complete an annual MDS for a resident with severe cognitive loss and multiple diagnoses, missing the required assessment in March 2024. The oversight was confirmed by the DON and the MDS Nurse, who acknowledged the missed annual assessment and the failure to combine the quarterly MDS into any PPS assessments.
The facility failed to develop and implement comprehensive care plans for two residents. One resident's care plan did not reflect new fractures and associated pain after a fall, while another resident's care plan was not updated to reflect a change in code status to DNR. These deficiencies were confirmed by the Director of Nurses and the Social Services Director.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure adequate RN coverage for 14 days across October, November, and December 2025 when the census was above 60 residents on those days. The record review showed that the facility did not have adequate RN coverage on multiple dates in October 2025, November 2025, and December 2025, despite its policy requiring sufficient nursing staff and the use of a RN for at least eight consecutive hours a day, seven days a week, unless waived. The policy also stated that a RN is to be designated as the full-time DON, who may serve as charge nurse only when the average daily occupancy is 60 or fewer residents. Interviews with the staffing scheduler, ADON, DON, and Administrator confirmed the staffing shortfalls. The staffing scheduler stated the facility had difficulty staffing RN coverage during October through December 2025 and that the DON and MDS Coordinator were sometimes used for RN coverage. The ADON stated the facility was aware of the failure to have adequate RN coverage during that period and had attempted to use agency staffing, but still had difficulty ensuring RN coverage due to the holidays. The DON and Administrator also acknowledged the lack of RN coverage and stated that agency staffing was attempted, but several days still had no RN present because RNs did not show up for work.
Expired and Unlabeled Medications Found in Carts and Medication Room
Penalty
Summary
Drugs and biologicals in the facility were not consistently labeled and expired medications were not removed from storage. Review of the facility policy showed that once multi-dose medications or biologicals are opened, nursing is to mark them with the date opened and follow manufacturer or supplier expiration guidance, and outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of according to medication destruction procedures. During observations, surveyors found an expired Buspirone 15 mg tablet card in the Dogwood 1 medication cart, an inhaler placed in a Ziploc bag without a prescription label, open Anero Ellipta, open Artificial Tears, and an Albuterol HFA inhaler with no open date label in the [NAME] Front medication cart, expired Even Care glucose control solutions in that cart, expired Even Care blood glucose test strips in the [NAME] Unit medication room, and an Albuterol Sulfate inhaler in the [NAME] Back medication cart with the meter reading 0 puffs. Interviews with the UM and DON indicated the carts and medication rooms were being audited on a weekly and monthly basis by nursing and pharmacy staff.
Posted and Master Menus Did Not Match Meals Served
Penalty
Summary
The facility failed to ensure that the master menu and the posted daily menu matched the meals actually served for two lunches for 4 of 4 residents reviewed. During observation, residents were served meals that did not match either the posted menu or their individual meal tickets. For lunch on 05/03/26, the posted menu listed chili with beef, tossed salad, cornbread, chilled fruit cup, and a beverage, while the master menu listed chili, baked potato, cornbread, and marble cake. However, residents were served items such as chili, plain baked potato, cheese sauce, and cake, and did not receive several items listed on their tickets or the posted menu. Similar mismatches were observed on 05/04/26, when the posted menu listed chicken and dumplings, steamed green beans, biscuit, chilled fruit cup, and beverage of choice, but residents were served chicken and dumplings, mixed vegetables, biscuit, margarine, and ice cream instead of the listed vegetables and fruit items. The Certified Dietary Manager stated he changed the lunch menu on 05/03/26 because residents voiced they did not want a baked potato with chili, and he said he did not change the master menu when changes were made. He also stated the evening meal was being changed from baked fish to stuffed cabbage rolls based on resident council feedback. The Dietician stated she was supposed to be notified immediately when the menu changed and was not aware of the Sunday lunch change. The Administrator stated the facility had no specific policy on posted menus matching what is served and that his expectation was that the posted menu would be what was served.
Infection Control: Improper Glove Use
Penalty
Summary
Provide and implement an infection prevention and control program was cited after a survey observation and interview showed inadequate glove use practices. The facility policy titled Indications for Glove Use states that gloves are discarded after each use with a patient or resident, changed when contaminated with blood or body fluids or before touching other parts of the same person, and that hand hygiene is performed immediately after gloves are removed before contact with another person or items in the environment. During an observation on 05/05/26 at 1:45 PM, RN2 was seen exiting a resident's room carrying a closed plastic bag with gloved hands and then entering the code to the soiled utility room while still wearing the soiled gloves. During an interview on 05/05/26 at 1:59 PM, RN2 confirmed wearing the gloves in the hallway and entering the soiled utility room, and stated the bag contained a soiled brief.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their conditions mentioned.
Failure to Administer Prescribed Tube Feeding Leads to Hypoglycemia
Penalty
Summary
The facility failed to ensure that a resident, identified as R281, received the prescribed tube feeding, which led to a significant drop in the resident's blood sugar levels. R281, who was admitted with diagnoses including malignant neoplasm of the base of the tongue, hypertension, and type 2 diabetes mellitus, was on a prescribed enteral feeding regimen of Osmolite 1.5 at 70 cc per hour for 22 hours daily. However, observations and interviews revealed that the resident was receiving water flushes instead of the prescribed tube feeding, causing his blood sugar levels to drop dangerously low. On the day of the incident, R281's blood sugar levels were recorded as low as 53, prompting the administration of Glucagon and glucose gel to stabilize his condition. Despite receiving insulin as per the physician's orders, the resident's blood sugar continued to drop, indicating that the tube feeding was not being administered as required. Interviews with the RN and observations confirmed that the pump was running water flushes instead of the nutritional formula, which was not detected until the surveyor's intervention. The Director of Nurses (DON) and the Nurse Practitioner (NP) were made aware of the situation, and it was discovered that the pump settings had not been properly adjusted, leading to the incorrect administration of fluids. The DON reviewed the pump's history and confirmed that the resident received significantly less tube feeding than prescribed over a 48-hour period. The oversight was attributed to a failure to check the pump settings, resulting in the resident's nutritional needs not being met and his blood sugar levels dropping to critical levels.
Failure to Provide Adequate Pain Management
Penalty
Summary
The facility failed to ensure that a resident, identified as R58, was free from significant pain. R58 was admitted with multiple diagnoses, including right knee pain, paraplegia, end-stage renal disease, and type 2 diabetes mellitus. Despite being cognitively intact, as indicated by a BIMS score of 13, R58 did not have any pain medication ordered or recorded in her Medication Administration Record (MAR) for February 2025. A Pain Assessment in Advanced Dementia Scale dated January 20, 2025, recorded a score of zero, indicating no pain, which contradicted the resident's reports and observations of significant pain. Interviews and observations revealed that R58 experienced severe pain in her right knee, which she rated as 10 out of 10, and was observed grimacing and wincing. Despite a nurse practitioner (NP) ordering Tylenol for the resident, the order did not go through due to a system glitch, and there was no follow-up to ensure the order was processed. The Director of Nurses (DON) acknowledged the issue with the electronic system and the lack of pain monitoring on the MAR. The resident expressed that she had been managing her pain by herself, indicating a lack of adequate pain management by the facility.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in the main walk-in refrigerator and dry storage areas, potentially affecting all 85 residents who consumed food from the kitchen. During an observation, it was noted that a can of beef base was open and dated, a plastic bag of chicken nuggets was open, not sealed or dated, and a plastic bag of french fries was open and not dated. In the dry storage area, approximately 18 cases of food were not put away and were on the floor, with several open cans directly on the floor without a pallet. Additionally, an open bottle of vanilla was not dated and had a missing lid, and various spices were open and not dated. A large salt bin was found open with the lid inside the salt. Interviews with staff revealed that the facility's policy required all open foods to be labeled and dated with an open date and expiration date. The Certified Dietary Manager confirmed that groceries need to be put away off the floor, and refrigerated items should be used within three days of opening. The Administrator stated that food should be put away by the next shift, stored six inches off the floor, and dated upon opening. The lids for storage should not be inside the food product. These observations and interviews indicate a failure to adhere to the facility's food safety policies, which could potentially impact the health and safety of the residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two medication rooms and two medication carts. During an inspection, it was found that a vial of Tubersol in the Dogwood Medication Room was opened, in use, and not dated as to when it was opened, contrary to the manufacturer's guidelines which require discarding 30 days after first use. Additionally, a Control E-Kit containing controlled substances was locked but not permanently affixed to the shelf, and an opened bottle of Urinalysis Reagent Strips was found to be expired. These findings were confirmed by a Registered Nurse. Further inspection of the Dogwood Medication Cart #1 and another medication cart revealed multiple insulin syringes that were either opened and not dated or unopened and improperly stored in the cart instead of the refrigerator, as per pharmacy labeling instructions. These observations were confirmed by two LPNs. Additionally, in another medication room, an empty controlled substance tackle box was found unsecured to the refrigerator shelf, and another expired bottle of Urinalysis Reagent Strips was noted. The Director of Nursing confirmed the findings and acknowledged the improper storage and labeling of medications.
Failure to Adhere to Medication Self-Administration Policy
Penalty
Summary
The facility failed to ensure a safe environment for Resident 231 by not adhering to its policy on self-administration of medications. The facility's policy requires an Interdisciplinary Care Team assessment for residents choosing to self-administer medications, and prohibits residents from storing controlled substances at the bedside. However, during an observation, Fluticasone spray was found on the windowsill in Resident 231's room, which the resident stated was left there for her to administer. This was despite the absence of a physician's order for self-administration or for the medication to be kept at the bedside. Further investigation revealed that the Licensed Practical Nurse (LPN) confirmed there was no order for Resident 231 to self-administer or have medication at the bedside. The LPN mentioned that over-the-counter medications are sometimes left at the bedside. The Director of Nursing (DON) stated that medications should not be left at the bedside and should be administered under observation, especially since the facility has wandering residents. Additionally, the DON noted that Resident 231 had been educated about this issue after stool softener was brought in by family without an order for self-administration.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during insulin administration. The deficiency was identified when a Licensed Practical Nurse (LPN) administered insulin to a resident without priming the insulin pen, as required by the facility's policy. The resident, who was admitted with diagnoses including hypoglycemia and Type 2 diabetes mellitus with diabetic neuropathy, had a physician's order for Insulin Lispro to be administered subcutaneously with meals and according to a sliding scale based on blood sugar levels. During an observation, the LPN administered 15 units of insulin to the resident after a blood sugar reading of 413, without priming the pen. The LPN acknowledged the oversight during an interview, and the Director of Nursing confirmed that priming the pen is a required step in the facility's medication administration procedure. This oversight constituted a significant medication error, as it deviated from the established protocol for insulin administration.
Failure to Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) for one resident, who was admitted with diagnoses including Parkinson's Disease, Hypertension, and a new diagnosis of Fracture Left Femur Neck. The resident had a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive loss. The last MDS completed for the resident was a quarterly assessment. The facility policy requires three quarterly reviews and one comprehensive assessment every 12 months. However, the resident's annual MDS, due in March 2024, was missed. Interviews with the Director of Nurses (DON) and the MDS Nurse confirmed the oversight, with the MDS Nurse acknowledging the missed annual assessment and the failure to combine the quarterly MDS into any of the Perspective Payment Plan (PPS) assessments.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, R2 and R3, as required by their policy. R2 was admitted with multiple diagnoses, including acute respiratory failure and fractures. After a fall resulting in new fractures, R2's care plan did not reflect these new injuries or the associated pain, despite the resident being placed on bedrest and wearing a splint. The Director of Nurses confirmed that the fractures and pain should have been included in the care plan. R3, who was admitted with severe cognitive impairment and other diagnoses, had a discrepancy in her care plan regarding her code status. Although her care plan initially indicated a Full Code status, a DNR order was signed later, and the care plan was not updated to reflect this change. The Social Services Director confirmed that the DNR should have been added to the care plan but was not. These failures indicate a lack of adherence to the facility's policy on maintaining accurate and comprehensive care plans for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 49 citations issued within 25 miles in the last 12 months — including the 6 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Summerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmark Healthcare Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Presbyterian Communities Of South Carolina-summerv | 5.1 mi | ★★★★★ | 2 | 0 |
| White Oak Manor - Charleston | 5.4 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Charleston | 6.1 mi | ★★★★★ | 4 | 0 |
| The Reserve Healthcare And Rehabilitation | 7.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oakbrook Health And Rehabilitation Center.
100% money-back within 48 hours.
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.