Oakwood Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Feb 20, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse by staff. This affected 1 of 3 residents (R1) reviewed for mental abuse. Staff held R1 down and forced R1 to be catherized against her wishes. As a result, R1 experienced severe trauma and fear, stating she did not feel safe in the facility and requested to be removed from the facility. The facility's failure to ensure R1 was free from abuse created a finding of immediate jeopardy that began on 2/01/25. Nursing Home Administrator (NHA) A, Director of Nursing (DON) B and [NAME] President of Success (VPS) G were notified of the immediate jeopardy on 2/12/25 at 3:32 PM. The immediate jeopardy was removed 02/01/25 and corrected on 02/03/25. […]

• Immediate jeopardy, isolatedF686Aug 26, 2024

  Based on observation, interview, and record review, the facility did not ensure each resident receives cares consistent with professional standards of practice to prevent pressure injuries (PIs) for 2 of 4 sampled residents (R)1 and R3. On admission 5/20/24, staff identified R1 had a suspected deep tissue injury (DTI) from the coccyx to the peri area. Physician, Director of Nursing, or wound nurse were not notified of this suspected DTI. No care plan or interventions were put in place for the pressure injury. Pressure injury assessments were not completed after the identification of the DTI on 5/20/24. As a result, R1 developed an unstageable pressure injury and sepsis. R1 required hospitalization and surgical debridement of the PI. The PI was staged as a stage 4 pressure injury. […]

• No harm, potential for more than minimal, widespreadF880Dec 18, 2024

  Based on observation, interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, or a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 39 residents in the facility. The facility did not have an adequate surveillance in place for tracking and monitoring infection and communicable disease for staff and residents. The facility did not ensure proper fitting N95 mask for staff with facial hair of a full beard. Facility staff did not dispose of contaminated Personal Protective Equipment (PPE) before exiting COVID positive rooms. […]

• No harm, potential for more than minimal, widespreadF880Jul 9, 2024

  Based on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 51 residents in the facility. The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for scabies. Multiple nursing staff members worked when they had scabies and were being treated, then worked on multiple other resident units, thus exposing other residents to scabies. […]

• No harm, potential for more than minimal, widespreadF812Oct 25, 2023

  Based on observations and interviews, the facility did not ensure food is not stored and or prepared under sanitary conditions. This has the potential to affect all 57 residents. Thermometer not cleaned before taking temperature of food. Gloved hands used to touch meat that has touched other surfaces. Gloves used to prepare food not changed between tasks. Cake cooled in front of an open window. Findings include: On 10/24/23 at about 11:38 AM, Surveyor observed Cook G grab thermometer from the shelf to take the temperature of beef tips. After Cook G took the temperature, they cleaned the thermometer with an alcohol wipe and put the thermometer back on the shelf. Surveyor interviewed Dietary District Manager (DDM) F and asked what their procedure was for taking temperatures of food. […]