Oakwood Community Living Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Jun 23, 2021

  Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed during dining when 3 of 5 staff members (Certified Nursing Assistant (CNA) #1, #2, and #3) failed to perform hand hygiene after touching contaminated objects while serving residents meals, failed to perform hand hygiene after removing gloves, failed to perform hand hygiene between serving residents, and failed to don proper Personal Protective Equipment (PPE) in isolation rooms, and when 1 of 2 dietary staff (Dietary Staff #1) observed washing dishes failed to perform hand hygiene after removing dirty gloves and donning clean gloves. […]

• No harm, potential for more than minimal, isolatedF605Nov 18, 2025

  Based on policy review, medical record review, and interview the facility failed to ensure the resident was free from unnecessary medication use when an as needed (PRN) order for a psychotropic medication was not updated for 1 of 2 (Resident #1) sampled residents reviewed for unnecessary medications.The findings include: 1. Review of the facility policy titled, Psychotropic Medication Use, dated 2/2025, revealed .Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record.Medications in the following categories are considered psychotropic medications Antianxiety medications .When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts… […]

• No harm, potential for more than minimal, isolatedF761Nov 18, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to store medication in accordance with facility policy when medication was found unsecured at the beside for 1 of 39 (Resident #35) residents. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated 2/2023, revealed .The facility stores all medications and biologicals in locked compartments .Only authorized personnel have access to keys .nursing staff is responsible for maintaining medication storage . 2. Review of the medical record revealed that Resident #35 was admitted to the facility on [DATE] with diagnoses including Dementia, Arthritis, and Back Pain. […]

• No harm, potential for more than minimal, isolatedF791Nov 18, 2025

  Based on policy review, medical record review, and interview, the facility failed to ensure dental services were provided for 1 of 1 (Resident #22) sampled resident reviewed for dental services. The findings include: 1. Review of the facility policy titled, Dental Services, dated 4/13/2021, revealed .It is the policy of this facility to make dental services available to residents requiring such services.Dental services are available to all residents requiring routine and emergency dental care.Social services will be responsible for assisting the resident/family in making necessary appointments. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Cerebral Aneurysm, Anxiety, and Depression. […]

• No harm, potential for more than minimal, isolatedF693Jun 23, 2021

  Based on policy review, observation, and interview, the facility failed to ensure 1 of 5 nurses (Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #3) administered medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube by gravity. The findings include: The facility's policy titled, ENTERAL TUBE MEDICATION ADMINISTRATION, dated 8/9/2013, revealed .To safely and accurately administer oral medications through an enteral tube .Allow medication to flow down tube via gravity .Do not push medications through the tube . Observation in the resident's room on 6/22/2021 at 1:06 PM, revealed RN #1 pulled 25 milliliters (ml) of water into a syringe, used the plunger to push the water into Resident #5's PEG tube. […]