Hartwyck at Oak Tree

In the surveyor’s words

From the most serious findings on record at Hartwyck at Oak Tree, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF919Dec 20, 2024

  Based on observations and interviews on 12/19/2024 in the presence of the Director of Maintenance (DOM), it was determined that the facility failed to ensure that the volume on the resident call bell system at the nurse's station on floor 3 was set to a level to be heard. This deficient practice had the potential to affect all residents and was evidenced by the following: An observation on at 11:50 AM revealed when the call bell was tested from resident room [ROOM NUMBER], there was no audible notification of the call bell activation. An observation at 11:55 AM revealed when the call bell was tested from resident room [ROOM NUMBER], there was no audible notification of the call bell activation. […]

• No harm, potential for more than minimal, isolatedF686May 29, 2026

  Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress (a specialized medical mattress that uses continuous airflow to prevent pressure ulcers, manage moisture, and enhance comfort for patients with limited mobility) was installed and checked for placement and function in accordance with a physician's order.This deficient practice was identified for 1 of 1 residents (Resident #52) reviewed for pressure ulcers and was evidenced by the following:On 5/19/26 at 10:02AM, the surveyor observed Resident #52 lying in bed with a dressing to the left lower leg. […]

• No harm, potential for more than minimal, isolatedF688May 29, 2026

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a physician's order and implement interventions for a resident with edema (swelling) to the left arm and left hand. This deficient practice was identified for 1 of 1 residents (Resident #96), reviewed for positioning and mobility and was evidenced by the following:On 5/19/26 at 10:02 AM, during the initial tour, the surveyor observed Resident #96 sitting in a wheelchair in the hallway with a flesh-colored sleeve and glove to the left arm and left hand. The resident stated, it is to keep the swelling down.On 5/20/26 at 11:25 AM, the surveyor observed Resident #96 in a wheelchair in the room with the left arm sleeve and left hand glove in place. […]

• No harm, potential for more than minimal, isolatedF880May 29, 2026

  Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to prevent the potential for cross contamination by not implementing Enhanced Barrier Precautions (EBP) (an infection control intervention designed to reduce transmission of multidrug-resistant organisms) for a resident with a tracheostomy (a surgical procedure that creates an opening in the neck allowing a patient to bypass their nose and mouth to breathe, receive mechanical ventilation, or clear mucus from their lungs) and an indwelling device (any tube/device left inside the body for an extended period) in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice and facility policy regarding the use of Personal… […]

• No harm, potential for more than minimal, isolatedF678Dec 20, 2024

  Based on observation, interview, and record review, it was determined that the facility failed to document the code status (medical instructions regarding resuscitation and other lifesaving measures in the event of a medical emergency) for 2 of 4 residents reviewed (Resident #31 and # 49) for code status. This deficient practice was evidenced by the following: 1. On 12/13/24 at 11:40 AM, during the initial tour, the surveyor observed Resident #31 in bed. The resident was observed with a tracheostomy and was dependent on a ventilator. The resident was not able to be interviewed. […]