Oakbend Medical Center

In the surveyor’s words

From the most serious findings on record at Oakbend Medical Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF584Jul 14, 2023

  Based on observation, interview, and record review, the facility failed to maintain a temperature range of 71 F to 81 F for 14 of 14 residents reviewed for exposure to high temperatures in the facility. -The facility air conditioning system had not been working adequately for up to two weeks. -The temperature of a common area (dining room) used by the residents was above 81 F. This failure placed all residents at risk for hyperthermia (elevated body temperature that could result in stroke or death). Findings Include: Observation on 06/27/2023 at 11:40 a.m. revealed the facility was a ground-floor wing of a multi-story hospital. Entry required walking through the main lobby and hallways. Observation during the walk revealed comfortable temperatures. […]

• No harm, potential for more than minimal, patternF578Jun 17, 2026

  Based on observation, interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 15 residents (Residents #161 and #163) reviewed for advance directives.The facility failed to ensure Resident #161's advance directive status met her directive to healthcare providers to not perform CPR if her breathing or heartbeat stopped. The facility failed to ensure Resident #163 had an out-of-hospital do-not-resuscitate form in his medical record that was consistent with his wishes. This failure could place residents at risk of not having their end-of-life wishes honored and having incomplete records. […]

• No harm, potential for more than minimal, patternF725Jun 17, 2026

  Based on interviews, and record review the facility failed to have sufficient and competent staffing to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 4 residents (Residents #1, #3, #4 and # 5) out of 7 residents.The facility failed to ensure a nursing staff responded to the call light in a timely manner on June 14,15,and 16th 2026.This failure could place residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. […]

• No harm, potential for more than minimal, patternF880Jun 17, 2026

  Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 5 residents (Resident #2 and Resident #4) and 2 of 2 staffs (CNA A, CNA B ) reviewed for infection control. -The facility failed to ensure CNA A proceed soiled linen accord to infection control policies and procedures. On 06/17/2026 CNA A placed Resident #2 soiled linen on the floor with ungloved hands. -The facility failed to ensure CNA B transported clean linen into Resident #4's room following infection prevention guidelines. CNA B held clean linen on her scrub. […]

• No harm, potential for more than minimal, patternF921Jun 17, 2026

  Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 2 hallways (Hall B) reviewed for environmental concerns.-The facility failed to ensure the ceiling in Hall B was free from water buildup, water pooling and a smoke damper leaking water on to the floor on 6/17/26. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings included:In an observation on Hall B on 6/17/26 at 10:04am, the following was observed: -Between rooms [ROOM NUMBERS], there was a ceiling tile that was stained with a brown and yellow stain that was about 7 inches wide and in the… […]