Oakdale Rehabilitation & Skilled Nursing Center

In the surveyor’s words

From the most serious findings on record at Oakdale Rehabilitation & Skilled Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF886Nov 14, 2022

  Based on test log review, and interview, the facility failed to ensure that its staff tested residents for COVID-19 at the appropriate frequency, when the facility was experiencing an outbreak of COVID-19. Specifically, staff failed to conduct testing of residents every 48 hours as required, on a unit with COVID-19 outbreak to stop the spread of infection. Findings include: Review of the Commonwealth of Massachusetts Executive Office of Health and Human Services Department of Public Health Memorandum, dated 10/13/22, titled: Update to Caring For Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, indicated the following: -Once a new case is identified in the facility, following the requisite outbreak testing,… […]

• No harm, potential for more than minimal, patternF880Jan 14, 2021

  Based on document review, record review, interview and observation, the facility A.) Failed to ensure staff properly monitored three residents (#1, #2, and #3) out of three applicable sampled residents, for fever based on the current threshold per the Centers for Disease Control and Prevention (CDC); B.) Failed to ensure staff properly removed Personal Protective Equipment (PPE), C.) Failed to ensure visitors were screened prior to entering the building, and D.) Failed to ensure staff wore face masks at all times, related to COVID-19. […]

• No harm, potential for more than minimal, isolatedF550Jun 11, 2025

  Based on observation, interview, and record review, the facility failed for one Resident (#187), with an indwelling urinary catheter (Foley Catheter/Foley - a tube placed through the urethra into the bladder to drain urine), out of a total sample of 19 residents, to maintain his/her Foley catheter in a privacy bag to maintain their dignity. Findings include: Review of Agency for Healthcare Research and Quality (AHRQ) article titled Catheter Care and Maintenance, published March 2017, retrieved from: https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/indwelling-urinary-catheter-use/catheter-care/slides.html indicated: -Residents sometimes prefer leg bags, which can improve mobility and dignity Resident #187 was admitted to the facility in June 2025… […]

• No harm, potential for more than minimal, isolatedF692Jun 11, 2025

  Based on observation, interview, and record review, the facility failed to provide appropriate care and nutrition services relative to an altered texture diet for one Resident (#14), out of a total sample of 19 residents. Specifically, the facility failed to provide Resident #14 with thickened beverages in accordance with the Resident's plan of care, placing Resident #14 at risk for swallowing complications. Findings include: Review of the facility's policy titled Therapeutic Diets, undated, indicated the following: -A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet or to alter the texture of a diet i.e.: altered consistency diet -A therapeutic diet… […]

• No harm, potential for more than minimal, isolatedF695Jun 11, 2025

  Based on observation, interview, and record review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for two Residents (#188 and #10), out of a total sample of 19 residents. Specifically, 1. For Resident #188, the facility failed to ensure that Physician orders with the appropriate liter flow were obtained for oxygen use when the Resident was being administered oxygen. 2. For Resident #10, the facility failed to obtain active Physician orders for the use of PRN (as needed) oxygen with the required liter flow when the Resident was being administered PRN oxygen. Findings include: Review of the facility's policy titled Oxygen, dated 2001, indicated: -Verify that there is a Physician's order for this procedure. […]