Oakwood Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF814Dec 31, 2025

  Based on observation, staff interviews, and policy review the facility failed to cover 3 garbage containers with lids. The facility reported a census of 64 residents. Findings include:On 12/29/25 at 1:30 PM observed the kitchen garbage next to the meal preparation table not actively in use, touching the surface of the table. The garbage can had the lid off and rested next to the garbage on the floor. On 12/31/25 at 10:40 AM observed the lid to the kitchen garbage on the floor propped up against the prep table near the storage of the disposable foam dishes. Witnessed the garbage by clean dishes and snack carts with 2 other garbage cans with the lids off by the drink cart. […]

• No harm, potential for more than minimal, patternF812Nov 7, 2024

  Based on observation, interviews and record review, the facility failed to ensure the chlorine in their dishwasher was at the correct level for sanitizing dishes. The facility reported a censure of 60 residents. Findings include: On 11/4/24 at 10:20 AM, the dishwasher was tested with a strip. The strip read between 25 Points Per Million (ppm) and 50 ppm. The kitchen staff stated they were going to look into this more. On 11/5/24 at 1:40 PM, the Housekeeping/Laundry Supervisor tested a new dishwasher strip. She stated it was between 50 ppm and 100 ppm. When the surveyor pointed out that the strip read between 25 ppm and 50 ppm, the supervisor concurred that it read between 25 ppm and 50 ppm. […]

• No harm, potential for more than minimal, isolatedF550Jul 23, 2026

  Based on clinical record review, facility policy review, staff, and resident interviews, the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 7 residents reviewed (Resident #1 and #10). The facility identified a census of 60 residents. Findings include: 1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 usually understands and feels understood, with adequate vision. The MDS documented a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. […]

• No harm, potential for more than minimal, isolatedF580Jul 23, 2026

  Based on clinical record review, staff and resident representative interview, the facility failed to notify a resident representative/family following a resident's fall for 1 of 6 residents reviewed (Resident #4). The facility reported a census of 60 residents. Findings include:Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented short and long-term memory problems with moderately impaired decision-making abilities, the ability to understand and receive understanding from others, and no present behaviors. Resident #4's MDS documented staff dependence for toileting hygiene, upper and lower body dressing, personal hygiene, transfers, and ambulation, alongside two falls without injury. […]

• No harm, potential for more than minimal, isolatedF609Jul 23, 2026

  Based on clinical record review, facility investigation, facility policy, staff and resident interview, the facility failed to report all alleged violations involving mistreatment and misappropriation of resident's property to the Department of Inspection and Appeals and Licensing (DIAL) within 2 hours for 2 of 2 residents reviewed (Resident #10 and #11). The facility reported a census of 60 residents. Findings include:1. Resident #10's Minimum Data Set (MDS) assessment dated [DATE] documented adequate vision and a Brief Interview for Mental Status (BIMS) score of 5, indicating severely cognitively impaired. Resident #10 usually understood others and others sometimes understood Resident #10. […]