ElderGrade

Inspection citations at Oak Trace

16 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 0
2025 9 1
2024 6 1
E March 20, 2026 Tag F0761 Corrected Mar 2026

Pharmacy Service Deficiencies

Ensure 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.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0759 Corrected Feb 2025

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0693 Corrected Feb 2025

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0686 Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0553 Corrected Feb 2025

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

No actual harm, potential for more than minimal harm

D January 17, 2025 Tag F0550 Corrected Feb 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E January 17, 2025 Tag F0689 Corrected Feb 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

E January 17, 2025 Tag F0625 Corrected Feb 2025

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

No actual harm, potential for more than minimal harm

F January 17, 2025 Tag F0812 Corrected Feb 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

G January 17, 2025 Tag F0692 Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Actual harm to a resident

G May 20, 2024 Tag F0689 Complaint investigation Corrected Jun 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D February 16, 2024 Tag F0695 Corrected Mar 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D February 16, 2024 Tag F0694 Corrected Mar 2024

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

D February 16, 2024 Tag F0690 Corrected Mar 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

E February 16, 2024 Tag F0880 Corrected Mar 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E February 16, 2024 Tag F0805 Corrected Mar 2024

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.