Oakwood Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Oakwood Care and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 12, 2021

  Based on staff interviews, observation and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVD-19) and other communicable diseases and infections. The facility failed to ensure they had a trained infection preventionist to effectively implement an adequate infection control program for the facility. This failure to have an effective infection control program contributed to the facility failing to identify their outbreak status based on county positivity rates and did not test staff accordingly. Furthermore, the facility failed to ensure staff were educated on policies and procedures of infection control. […]

• Immediate jeopardy, patternF600Oct 9, 2023

  Based on interviews, record review, and observations, the facility failed to protect six of nine residents reviewed out of 22 sample residents (#14, #20, #21, #15, #16, and #17) from incidents of resident-to-resident abuse and neglect. A. Record review revealed the facility failed to take steps to develop and implement effective interventions to create an environment in the memory care (secure) unit that protected residents from repeated incidents of resident-to-resident abuse. Residents #14, #20, #16, #17, and #21 resided in the facility's secure unit, along with 20 other residents. Residents #14, 21, #16, #17, and #21 were cognitively impaired and all had the potential for aggressive behavior toward other residents and/or staff. […]

• Immediate jeopardy, isolatedF689May 4, 2023

  Based on observations, interviews, and record review, the facility failed to ensure three residents (#1, #2 and #3) of three residents out of 13 residents at moderate/high risk for elopement, received adequate supervision and assistive devices to prevent accidents. The facility failed to provide Residents #1, #2 and #3 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions) and mood disorder, eloped from the facility on 4/2/23 at 2:00 p.m. when he signed out. […]

• Actual harm, isolatedF600Jan 29, 2025

  Based on observations, record review and interviews, the facility failed to ensure four (#1, #8, #7 and #27) of 11 residents reviewed for abuse out of 28 sample residents were kept free from abuse. Resident #2 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. Resident #2's care plan documented he had potential to demonstrate physically and verbally aggressive behaviors due to his diagnosis of dementia. […]

• Actual harm, isolatedF600Apr 10, 2024

  Based on interviews and record review, the facility failed to ensure four (#79, #60, #31, #13) of four residents reviewed for abuse out of 48 sample residents were kept from mental and verbal abuse, contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. I. Staff to resident mental and verbal abuse A. In interviews with Resident #79, she stated the activities director (AD) was mean to her, spoke to her rudely, raised her voice at her, and made her feel belittled and like a scolded child on 4/3/24. Resident #79 was upset and was tearful as she recalled the incident. […]