Delta Oaks Post Acute Complaints, Violations and Inspection Records

June 9, 2026, complaint inspection

4 deficiencies cited. Surveyors cited the facility for protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody, develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, and ensure services provided by the nursing facility meet professional standards of quality.

• F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (scope and severity D)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity D)
• F0685Assist a resident in gaining access to vision and hearing services. (scope and severity D)

April 21, 2026, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies and develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

• F0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. (scope and severity D)
• F0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (scope and severity D)

April 15, 2026, complaint inspection

4 deficiencies cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, provide and implement an infection prevention and control program, and ensure that residents are free from significant medication errors.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity G)
• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0760Ensure that residents are free from significant medication errors. (scope and severity D)
• F0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (scope and severity D)

April 2, 2026, complaint inspection

4 deficiencies cited. Surveyors cited the facility for develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals, timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities, and respond appropriately to all alleged violations.

• F0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (scope and severity E)
• F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (scope and severity D)
• F0610Respond appropriately to all alleged violations. (scope and severity D)
• F0637Assess the resident when there is a significant change in condition (scope and severity D)

March 5, 2026, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)

February 17, 2026, complaint inspection

2 deficiencies cited. Surveyors cited the facility for develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured and provide safe, appropriate pain management for a resident who requires such services.

• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0697Provide safe, appropriate pain management for a resident who requires such services. (scope and severity D)

December 30, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure each resident must receive and the facility must provide necessary behavioral health care and services.

• F0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (scope and severity D)

December 4, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for dispose of garbage and refuse properly.

• F0814Dispose of garbage and refuse properly. (scope and severity D)

November 24, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

• F0627Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. (scope and severity D)

October 2, 2025, standard inspection

15 deficiencies cited. Surveyors cited the facility for honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights, ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, and provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity E)
• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity E)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity E)
• F0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (scope and severity E)
• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity E)
• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (scope and severity D)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (scope and severity D)
• F0692Provide enough food/fluids to maintain a resident's health. (scope and severity D)
• F0745Provide medically-related social services to help each resident achieve the highest possible quality of life. (scope and severity D)
• F0757Ensure each resident’s drug regimen must be free from unnecessary drugs. (scope and severity D)
• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity D)
• F0883Develop and implement policies and procedures for flu and pneumonia vaccinations. (scope and severity D)
• F0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. (scope and severity D)

September 25, 2025, complaint inspection

3 deficiencies cited. Surveyors cited the facility for develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured, provide appropriate care for a resident to maintain and/or improve range of motion (rom), limited rom and/or mobility, unless a decline is for a medical reason, and ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (scope and severity D)
• F0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (scope and severity D)

August 22, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide and implement an infection prevention and control program.

• F0880Provide and implement an infection prevention and control program. (scope and severity D)

August 8, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)

June 25, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for respond appropriately to all alleged violations.

• F0610Respond appropriately to all alleged violations. (scope and severity D)

June 18, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity E)

June 5, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide care and assistance to perform activities of daily living for any resident who is unable.

• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity D)

May 27, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

• F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (scope and severity D)

May 15, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

• F0628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. (scope and severity E)

April 8, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity G)

February 6, 2025, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity D)

November 5, 2024, complaint inspection

3 deficiencies cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist, and provide and implement an infection prevention and control program.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity D)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)

October 22, 2024, complaint inspection

4 deficiencies cited. Surveyors cited the facility for reasonably accommodate the needs and preferences of each resident, provide care and assistance to perform activities of daily living for any resident who is unable, and ensure each resident’s drug regimen must be free from unnecessary drugs.

• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity D)
• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity D)
• F0757Ensure each resident’s drug regimen must be free from unnecessary drugs. (scope and severity D)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)

October 18, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for provide and implement an infection prevention and control program and honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (scope and severity D)

September 4, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide appropriate treatment and care according to orders, resident’s preferences and goals.

• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity E)

August 22, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide and implement an infection prevention and control program.

• F0880Provide and implement an infection prevention and control program. (scope and severity D)

August 1, 2024, standard and complaint inspections

20 deficiencies cited. Surveyors cited the facility for procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards, reasonably accommodate the needs and preferences of each resident, and provide safe and appropriate respiratory care for a resident when needed.

• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity F)
• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity E)

• F0695Provide safe and appropriate respiratory care for a resident when needed. (scope and severity E)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity E)
• F0760Ensure that residents are free from significant medication errors. (scope and severity E)
• F0813Have a policy regarding use and storage of foods brought to residents by family and other visitors. (scope and severity E)
• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity D)
• F0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (scope and severity D)
• F0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (scope and severity D)
• F0610Respond appropriately to all alleged violations. (scope and severity D)
• F0645PASARR screening for Mental disorders or Intellectual Disabilities (scope and severity D)
• F0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (scope and severity D)
• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity D)
• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)
• F0692Provide enough food/fluids to maintain a resident's health. (scope and severity D)
• F0694Provide for the safe, appropriate administration of IV fluids for a resident when needed. (scope and severity D)
• F0697Provide safe, appropriate pain management for a resident who requires such services. (scope and severity D)
• F0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (scope and severity D)
• F0791Provide or obtain dental services for each resident. (scope and severity D)

July 17, 2024, complaint inspection

4 deficiencies cited. Surveyors cited the facility for provide appropriate treatment and care according to orders, resident’s preferences and goals, immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident, and provide timely, quality laboratory services/tests to meet the needs of residents.

• F0684Provide appropriate treatment and care according to orders, resident’s preferences and goals. (scope and severity G)
• F0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (scope and severity D)

• F0770Provide timely, quality laboratory services/tests to meet the needs of residents. (scope and severity D)
• F0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (scope and severity D)

July 16, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for let each resident or the resident's legal representative access or purchase copies of all the resident's records.

• F0573Let each resident or the resident's legal representative access or purchase copies of all the resident's records. (scope and severity D)

June 11, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents and provide and implement an infection prevention and control program.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)
• F0880Provide and implement an infection prevention and control program. (scope and severity D)

June 10, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

• F0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (scope and severity D)

May 30, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation and timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

• F0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (scope and severity E)
• F0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (scope and severity D)

May 28, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for reasonably accommodate the needs and preferences of each resident and ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity E)
• F0807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. (scope and severity E)

March 18, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

• F0557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (scope and severity D)

March 15, 2024, complaint inspection

2 deficiencies cited. Surveyors cited the facility for reasonably accommodate the needs and preferences of each resident and ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity E)
• F0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. (scope and severity E)

January 3, 2024, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

• F0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (scope and severity F)

December 28, 2023, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide and implement an infection prevention and control program.

• F0880Provide and implement an infection prevention and control program. (scope and severity E)

November 8, 2023, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide care and assistance to perform activities of daily living for any resident who is unable.

• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity D)

October 24, 2023, complaint inspection

1 deficiency cited. Surveyors cited the facility for honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

• F0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (scope and severity E)

September 26, 2023, complaint inspection

1 deficiency cited. Surveyors cited the facility for provide safe and appropriate respiratory care for a resident when needed.

• F0695Provide safe and appropriate respiratory care for a resident when needed. (scope and severity D)

July 20, 2023, standard inspection

17 deficiencies cited. Surveyors cited the facility for ensure services provided by the nursing facility meet professional standards of quality, provide care and assistance to perform activities of daily living for any resident who is unable, and provide appropriate care for a resident to maintain and/or improve range of motion (rom), limited rom and/or mobility, unless a decline is for a medical reason.

• F0658Ensure services provided by the nursing facility meet professional standards of quality. (scope and severity E)
• F0677Provide care and assistance to perform activities of daily living for any resident who is unable. (scope and severity E)

• F0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (scope and severity E)
• F0730Observe each nurse aide's job performance and give regular training. (scope and severity E)
• F0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (scope and severity E)
• F0759Ensure medication error rates are not 5 percent or greater. (scope and severity E)
• F0760Ensure that residents are free from significant medication errors. (scope and severity E)
• F0761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. (scope and severity E)
• F0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (scope and severity E)
• F0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (scope and severity E)
• F0868Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (scope and severity E)
• F0880Provide and implement an infection prevention and control program. (scope and severity E)
• F0558Reasonably accommodate the needs and preferences of each resident. (scope and severity D)
• F0561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (scope and severity D)
• F0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (scope and severity D)
• F0693Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (scope and severity D)
• F0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (scope and severity D)