Oaklawn Health Care, LLC

In the surveyor’s words

From the most serious findings on record at Oaklawn Health Care, LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 27, 2023

  Based on observation, interview, and document review the facility failed to ensure safe mechanical lift transfers were completed along with following manufacturer guidelines for Med Care lift that expired, and ensuring correct sling/harness sizes for 7 of 7 residents (R4, R5, R6, R7, R8, R9, R10) who utilized this mechanical lifts. This resulted in an immediate jeopardy (IJ) for R1 who fell from the Med Care sit to stand lift resulting a fractured right femur (thigh bone) on [DATE]. This had the likelihood for serious harm, impairment or death for R4, R5, R6, R7, R8, R9 and R10 who continued to use this Med Care sit to stand lift. […]

• Actual harm, isolatedF686Apr 9, 2021

  Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 1 resident (R84) reviewed who had a stage 4 pressure ulcer with known risks for pressure ulcer development. The facility's failures resulted in R84 sustaining harm when the resident developed an unstageable pressure ulcer to the left heel. Findings include: Pressure ulcer stages, identified from the National Pressure Ulcer Advisory Panel (NPUAP): Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. […]

• No harm, potential for more than minimal, widespreadF921Jun 10, 2026

  Based on observation, interview and document review, the facility failed to ensure a safe, sanitary and comfortable environment for 1 of 1 residents (R2) whose room was unkept and had resident care items placed on the floor. In addition, the facility failed to perform daily cleaning in the kitchen which had the potential to affect 54/56 residents who received food from the kitchen. Findings include:R2R2's face sheet received on 6/10/26, included diagnoses of diabetes, dementia, and chronic gastritis (inflammation of stomach lining).R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. […]

• No harm, potential for more than minimal, widespreadF585Aug 9, 2023

  Based on observation, interview and document review, the facility failed to establish a grievance policy to ensure residents could voice grievances anonymously and without fear of discrimination or reprisal. In addition, the facility failed to post in prominent locations throughout the facility the right to file grievances orally or in writing; the right to file grievances anonymously; and the name and contact information of the grievance official with whom a grievance could be filed. This deficient practice had the potential to affect all 50 residents and visitors in the facility. Findings include: During an observation on 8/9/23 at 10:00 a.m., the facility lacked a posting of the grievance process as well as no grievance forms were available in prominent locations in the facility. […]

• No harm, potential for more than minimal, widespreadF755Apr 9, 2021

  Based on observation, interview and document review, the facility failed to ensure a system for periodic reconciliation of controlled or narcotic medications in 1 of 1 emergency kit (E-Kit) to prevent potential loss or diversion. This had the potential to affect any of the 52 residents present in the facility who may require controlled medications from the E-Kit. Findings include: On 4/9/21, at 9:20 a.m., a tour of the North unit medication room was conducted with licensed practical nurse (LPN)-B. Located within the medication room was a refrigerator with an E-Kit with a green unnumbered tag present that included lorazepam (an anti-anxiety medication/controlled substance). […]