Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 3 | 0 |
| Riviere De Soleil Community Care Center | 13.4 mi | — | 5 | 0 |
| Legacy Nursing At St. Christina | 13.5 mi | — | 17 | 0 |
| Hilltop Nursing & Rehabilitation Center | 13.6 mi | — | 13 | 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 August 2026) and official state health department websites.