Oaks on Parkwood Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Oaks on Parkwood Skilled Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 28, 2025

  Based on interviews, medical record review, review of a third-party complaint received by the State Agency (SA), and review of the facility's investigative file the facility failed to ensure a process was developed and implemented to ensure the doors leading into the kitchen from the main dining room were locked when the kitchen staff were not present. On 05/18/2025, one of the two doors leading from the main dining room into the kitchen was not locked after dietary staff left for the evening. Resident Identifier (RI #141) entered the kitchen through the unlocked door, secured two knives and stabbed him/herself five times in the chest/abdomen area. A facility staff member heard RI #141 in the kitchen and responded. […]

• No harm, potential for more than minimal, widespreadF838Oct 15, 2021

  Based on interview, record review, and review of Oaks on Parkwood Highlands Rehabilitation and Skilled Nursing Facility Assessment 2021 the facility failed to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This had the potential to affect 84 of 84 residents in the facility. Findings Include: A review of Oaks on Parkwood Highlands Rehabilitation and Skilled Nursing Facility Assessment 2021 revealed . III. Facility Assessment of Care Required by Resident Population . B. […]

• No harm, potential for more than minimal, widespreadF803May 20, 2021

  Based on observation, interview, review of the facility's policies titled Food Preparation Principles and Menus, Cycle and Meal Schedule, and review of the facility's Diet Spreadsheet, the facility failed to ensure: 1.) the portion size for fruit juice as documented on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was served to residents at breakfast; 2.) the portion size for Scalloped Potatoes and for Pureed Scalloped Potatoes as documented on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was served to residents at lunch; and 3.) portion sizes were identified for Mixed Vegetables on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, for the lunch meal. […]

• No harm, potential for more than minimal, widespreadF804May 20, 2021

  Based on observation, interviews, and review of a facility policy titled Food Preparation Principles, the facility failed to ensure residents received hot foods at palatable temperatures. This had the potential to affect 85 of 85 residents receiving meals in the facility. Findings include: Review of a facility policy titled Food Preparation Principles, effective 6/2018, revealed the following: . STANDARD: . Food . should be served . at proper temperatures. On 5/18/2021 at 5:52 PM, the surveyor observed Resident Identifier (RI) #6's supper meal. RI #6 received a bowl of chicken noodle soup with the meal. As RI #6 began to eat the soup, he/she reported to the surveyor the soup was cold. RI #6 said, Please stick your finger in it. I am not going to eat it. […]

• No harm, potential for more than minimal, patternF600Sep 28, 2025

  Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect, and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by staff and residents. The facility further failed to supervise combative, agitated residents and wandering residents in a manner to prevent abuse of residents.Specifically:1.) The facility failed to protect Resident Identifier (RI) #137 from verbal abuse perpetrated by Nurse Aide Trainee (NAT) #17. On 05/04/2024 Certified Nursing Assistant (CNA) #16 witnessed RI #137 curse at NAT #17, then NAT #17 responded by calling RI #137 a bitch. […]