NHC Healthcare, Oakwood

In the surveyor’s words

From the most serious findings on record at NHC Healthcare, Oakwood, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Jan 22, 2026

  Based on the facility's Work In/Out Report and interviews the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 2 of 30 days reviewed. The facility's census was 51. The findings include: Review of the facility's Work In/Out Report for time punches dated 1/10/2026, revealed RN A worked from 12:00 AM until 12:45 AM and RN A and RN B worked from 7:00 PM until 12:00 AM, which provided a period of 5 hours of RN coverage, resulting in no RN coverage for 8 consecutive hours. The facility was unable to provide documentation of RN coverage between 12:46 AM and 6:59 PM, resulting in no consecutive 8 hour interval of RN coverage for 1/10/2026. […]

• No harm, potential for more than minimal, widespreadF809Mar 9, 2022

  Based on facility policy review, medical record review, documentation review, and interview, the facility failed to ensure there was no more than 14 hours between a substantial evening meal and breakfast the following day. The findings include: Review of facility's policy titled, Meal Service & Patient Meal Delivery, dated 11/2020, revealed, .The center will provide meals with no greater than a 14-hour lapse between the evening meal and breakfast (or 16 hours with approval of a resident group and provision of a substantial snack) . Review of the undated facility documentation titled, Meal Service Schedule, revealed 15 hours between the evening meal at 4:00 PM and the breakfast meal at 7:00 AM. […]

• No harm, potential for more than minimal, widespreadF812Mar 9, 2022

  Based on facility policy review, observations, and interviews, the facility failed to ensure food was served in a sanitary manner for 46 of 47 residents served a meal tray from the kitchen. The findings include: Review of the facility's policy titled, Glove Use, revised 11/2017, revealed, .Change gloves before moving from one task to another .partners shall have no bare hand contact with food and shall use appropriate items such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment when handling food .Gloves should never replace the use of utensils, tongs, etc . […]

• No harm, potential for more than minimal, patternF657Mar 9, 2022

  Based on facility policy review, medical record review, and interview, the facility failed to complete a Care Conference after each completed resident assessment for 9 of 27 sampled residents (Residents #2, #3, #6, #16, #21, #23, #39, #41, and #42) reviewed. The facility also failed to revise a Care Plan for 1 of 27 sampled residents (Resident #23) reviewed. The findings include: Review of the facility policy titled, Updating and Revising Care Plans, dated [DATE], revealed, .Routine Reviews and Updates: Care plans are updated as needed but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of the completion of the clinical MDS [Minimum Data Set] assessment . […]

• No harm, potential for more than minimal, isolatedF550Jan 22, 2026

  Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote dignity for 1 of 1 (Resident #39) sampled residents reviewed for indwelling urinary catheter (plastic tube inserted into the bladder to drain urine).The findings include: 1. Review of the facility policy titled, Patient Rights, dated 9/2024, revealed .Privacy.we provide you with privacy so that you may maintain a dignified existence, self-determination. 2. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Aphasia, Obstructive and Reflux Uropathy (a condition that prevents normal urine flow), and Hypertensive Heart and Chronic Kidney Disease. […]