Oakwood Health and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF725May 19, 2022

  Based on resident interview, family interview, staff interview, observation, and clinical record review, the facility staff failed to provide sufficient nursing staff to ensure care and services were provided to maintain the highest practicable well-being for 11 of 22 residents in the survey sample, residing on three of three floors, Residents #188, #73, #80, #238, #11, #20, #62, #51, #35, #47, and #9. Resident #188 did not receive pain medication as ordered, which was identified as harm. Call bells were not answered in a timely manner as evidenced by resident and family interviews, and as documented in the resident council meeting minutes. Eight residents did not receive skin and/or wound care evaluations, Residents #73, #80, #238, #11, #20, #62, #51, and #35. […]

• Immediate jeopardy, isolatedF658Oct 26, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of twelve residents in the survey sample (Resident #1). Facility staff failed to clarify with the provider a new order to administer 100 units of short-acting insulin at each meal, when Resident #1 was intended to receive 20 units with meals. Resident #1 received a total of 200 units of short-acting insulin in a 4-hour period leading to life-threatening hypoglycemia, requiring hospitalization in the intensive care unit for treatment of the insulin overdose (serious harm). […]

• Immediate jeopardy, isolatedF760Oct 26, 2023

  Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure one of twelve residents in the survey sample (Resident #1) was free from a significant medication error. Facility staff entered an erroneous order to administer an 100-unit dose of short-acting insulin with meals, when Resident #1 was intended to get 20 units with meals. Resident #1 (R1) was administered a total of 200 units of short-acting insulin in a 4-hour period based upon this order, leading to life-threatening hypoglycemia (low blood sugar) requiring immediate treatment of the insulin overdose and subsequent hospitalization in the intensive care unit (serious harm). […]

• Actual harm, isolatedF697May 19, 2022

  Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide effective pain management for one of 22 residents, Resident #188. Resident #188 reported on two separate occasions, her pain medication was delayed and/or not available for administration resulting in extreme pain greater than ten (on a scale of 1-10) and through the roof. This is harm. The findings were: Resident #188 was admitted to the facility with the following diagnoses, including but not limited to: Displaced bimalleolar fracture of right lower leg, hypo-osmolality and [CONDITION(S)], [CONDITION(S)], hypertension, [CONDITION(S)], and cerebral infarction. Due to Resident #188's recent admission there was no MDS (minimum data set) assessment completed. […]

• No harm, potential for more than minimal, widespreadF812Jul 26, 2023

  Based on observations, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent potential foodborne illness for 93 out of 94 residents (1 resident was receiving tube feedings). Specifically, the main kitchen freezer was found to have improperly labeled foods in the freezer and three out of four-unit pantry refrigerators were found to be improperly labeled and had expired food items. This failure had the potential to expose residents to expired and/or spoiled food, unknown allergens, and food items that were not in compliance with current dietary orders. […]