Oakwood Health Campus

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 20, 2025

  Based on interview and record review, the facility failed to provide a resident appropriate care and services for 1 of 1 resident reviewed for hospitalizations. The resident was not thoroughly assessed, physician's orders were not followed, and staff were not adequately trained to provide care of a resident with a recent vascular stent placement. This deficient practice resulted in the resident being hospitalized . (Resident 89) Finding includes:On 8/14/25 at 1:01 P.M., Resident 89's clinical record was reviewed. […]

• No harm, potential for more than minimal, patternF656Aug 20, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 5 residents reviewed for unnecessary medications and 1 of 1 residents reviewed for dialysis. Care plans lacked resident specific diagnoses and interventions. (Resident 1, Resident 33, Resident 54, Resident 55, Resident 86)Findings include:1. On 8/15/25 at 12:34 P.M., Resident 54's clinical record was reviewed. Diagnoses included, but were not limited to, osteoarthritis, anxiety, and depression. The most recent admission Minimum Data Set (MDS) assessment, dated 7/30/25, indicated resident 54 was cognitively intact and partial to moderate assistance of staff (staff performs less than half the effort) for transfers and toileting. […]

• No harm, potential for more than minimal, patternF812Aug 20, 2025

  Based on observation and interview, the facility failed to ensure food was served in accordance with professional standards for 1 of 1 kitchen observed. Staff picked food up with soiled gloves, placed on top of resident's food, and served plate to residents. (Kitchen)Finding includes:During a dining room observation on 8/13/25 at 11:39 A.M., three residents were observed sitting at a table. Each plate at the table was observed with a plastic packet of butter sitting on top of the food. At that time, kitchen staff member was observed to bring out a plate of food from the kitchen with a plastic butter packet sitting on top of the food on the plate. It was then served to a resident. On 8/13/25 at 11:52 A.M., Kitchen Staff 23 was observed plating food in the kitchen. […]

• No harm, potential for more than minimal, patternF921Aug 24, 2023

  Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment during random room observations and including 4 of 7 resident restrooms reviewed for water temperatures. Water temperatures were greater than the maximum temperature of 120 degrees Fahrenheit (F), resident personal hygiene items were open to air or stored on the bathroom floor, and an air conditioning unit was leaking onto the carpet in a resident room. (Resident B, Resident C, Resident F, Resident G, room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF605Aug 20, 2025

  Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications. A resident's antipsychotic was changed without attempts of non-pharmacological interventions, and received more than the recommended dose of an antipsychotic medication when switching from one antipsychotic medication to another. (Resident 33)Finding includes:On 8/14/25 at 10:43 A.M., Resident 33's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, dementia, anxiety, and depression. Resident 33 was admitted on [DATE]. The most recent admission Minimum Data Set (MDS) assessment, dated 7/1/25, indicated a severe cognitive impairment, and use of an antipsychotic medication. […]