Oakwood Gardens Care Center

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 22, 2022

  Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when the nursing staff did not identify and provide needed care for four of four residents (Residents 6, 13, 14 and 15) when: 1. Nursing assessments and documentation for Residents 6, 13, 14 and 15 were not performed in accordance with the Centers for Disease Control (CDC- U.S. federal government agency whose mission is to protect public health by preventing and controlling disease, injury, and disability) recommendations for residents with COVID-19 (Coronavirus [[CONDITION(S)]-CoV -2] - a contagious serious respiratory infection transmitted from person to person) infections. […]

• No harm, potential for more than minimal, widespreadF804Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure food reached the appropriate and safe temperature when the dietary cook did not check and document food temperatures for the lunch meal on 6/30/26. This failure had the potential to result in all residents receiving food from the kitchen that did not reach the appropriate and safe temperature and not eating their meal and placed their nutritional status at risk, which could potentially lead to weight loss. During an observation on 6/30/26 between 11:55 a.m. through 12:55 p.m. in the kitchen during tray line, observed Dietary [NAME] (DC) placed cooked food on the steam table, placed thermometers (tool used to measure how hot or cold something is) in the food trays and left thermometers for at least a minute. […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure food were stored, prepared and served in accordance with professional standards for safety when: 1. Food was found unlabeled and there was opened foods in the freezer and in the walk in dry storage room with no open or used by date. 2. Expired and unlabeled items were found in the resident's food refrigerator in the hallway near the nursing station, three and four. These failures had the potential to cause the growth of microorganisms (organisms that are too small to be seen with the naked eye) and spread foodborne illness (disease or period of sickness caused by food contamination) to the residents that were served meals from the kitchen. 3 . […]

• No harm, potential for more than minimal, widespreadF814Jul 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions when three out of four outdoor dumpsters were observed with lids open and overflowing. This failure had the potential to attract pests, create offensive odors and negatively impact food safety and the overall sanitary environment of the facility. During a concurrent observation and interview on 6/29/26 at 6:15 a.m. during the initial tour of the facility with the Certified Dietary Manager (CDM), the facility's dumpsters located behind the building were observed with lids not completely closed. Three dumpsters contained overflowing with garbage in plastic garbage bags, which prevented the lids from closing securely. […]

• No harm, potential for more than minimal, widespreadF761Feb 17, 2023

  Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with current accepted professional standards of practice when: 1. Resident 34's Lorazepam (a medication used to treat anxiety disorders, trouble sleeping, severe agitation, active seizures including status epilepticus, alcohol withdrawal, and chemotherapy-induced nausea and vomiting) was discontinued on 2/11/13 and the medication was not separated from active medications and was stored in medication cart. 2. […]