Oakland Manor

In the surveyor’s words

From the most serious findings on record at Oakland Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF684Dec 20, 2021

  Based on observation, record review, and resident, family, and staff interviews, the facility failed to complete assessments, implement interventions, and provide medication and wound care in accordance with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 admitted from the hospital on 7/23/21 for skilled care due to worsening of pulmonary hypertension and heart failure. The facility failed to provide daily assessments and failed to administer any of her medications; this resulted in re-hospitalization on [DATE] for chest pain, increased [CONDITION(S)] (swelling) with weeping extremities, and shortness of breath. Resident #15 admitted to the facility on [DATE] with a venous wound to her left lower leg. […]

• Immediate jeopardy, patternF695Dec 20, 2021

  Based on observations, record review, and resident and staff interviews, the facility failed to provide tracheotomy care, tracheal suctioning, and aerosol drug administration, in accordance with professional standards of practice for 6 of 7 residents reviewed (Resident #2, 3, 6, 7, 11 and 12). Resident #2 was dependent on a ventilator related to chronic [CONDITION(S)]. On [DATE] at 3:46 AM, his ventilator alarmed displaying low ventilation. The nurse suctioned him, but the ventilator continued to alarm. The facility called an ambulance and began rescue breathing with an ambu bag. When EMS arrived, they found Resident #2 unresponsive and suspected a plugged [CONDITION(S)]. […]

• Actual harm, isolatedF689Jul 9, 2025

  Based on resident interviews, staff interviews, clinical record review and staff file review, the facility failed to prevent accidents for 1 of 7 residents. Resident #36 slid from her wheelchair while being transported to an appointment in the facility van. The staff failed to ensure that the resident was stabilized by applying the shoulder strap of the seat belt. The facility reported a census of 47 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficits). She required substantial assistance with dressing, toileting, hygiene, and was totally dependent on staff for transfers. […]

• Actual harm, isolatedF693Jul 9, 2025

  Based on electronic medical record (EMR) review, resident interview, staff interviews, and policy review the facility failed to provide care and service to an individual with a feeding tube resulting in complication of enteral feeding and medication administration for 1 of 1 residents reviewed (Resident #1). The facility failed to identify the skills and abilities needed of the direct care staff when providing enteral medications to the resident resulting in 4 hospital visits including 3 overnight stays within 4 weeks. The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 4/18/25 revealed the Brief Interview for Mental Status (BIMS) score of 10/15 indicating moderate cognitive deficit. […]

• Actual harm, isolatedF684Aug 31, 2023

  Based on clinical record review, CDC guidelines, staff interviews, physician interview and facility policy review the facility failed to provide timely assessments and interventions for 3 of 13 residents reviewed (Resident #46, #8 and #37). Resident #46 had a urinary tract infection (UTI) and was on an antibiotic. Staff failed to conduct daily vital signs and did not contact the provider when his condition worsened. The resident went to the hospital in septic shock due to a kidney infection. Daily skilled nurse charting for Resident #8 and Resident #37 showed that staff used vital signs from previous days. The facility reported a census of 45 residents. Findings include: 1. […]