Oakwood Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689May 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents remained free from potential accident hazards when: 1. One Fire Door (FD) A (a door that is fire proof and helps contain smoke), which led to the outside of the facility was damaged and could not be completely closed or locked for the past year and a half. The door led to the facility backyard where there was a steep creek. 2. A staff locker room door (LD) B, that residents had access to, was not kept locked and contained rusty unlocked lockers, stainless steel chemical cleaner, personal protective equipment (eye goggles, face shield and face masks), staff belongings, food items, a broken air conditioner, TV monitors [televisions], cardboard boxes, an industrial-sized container of a chemical rust… […]

• Actual harm, isolatedF689Nov 6, 2025

  Based on observation, interview, and record review, the facility failed prevent an avoidable fall with injuries when staff had not correctly used a Hoyer lift (a mechanical device with a sling that has straps which are to be securely attached to the device used to lift and carry a resident to a desired location. This lift requires two staff for a safe transfer, one to operate the lift and one to guide the resident), for one of five sampled residents (Resident 1) when:1a. Staff had not ensured the straps on the Hoyer lift were secure and the sling straps came off and dropped Resident 1 onto the floor.1b. While one staff operated the Hoyer lift, the second staff had not stood by and guided Resident 1 during the transfer.1c. […]

• Actual harm, isolatedF686May 28, 2024

  Based on observation, interview, and record review, the facility failed to identify, evaluate, and intervene in a timely manner in order to prevent an avoidable pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence, where bones are close to the surface of the skin), for 1 of 3 residents who were sampled for pressure ulcers (Resident 63). This resulted in Resident 63 developing an infected Stage 4 (full thickness skin loss with damage and exposure of muscle, bone, fat and/or tendon), pressure ulcer on his right heel and subsequent right leg amputation (cut off by surgical operation), below the knee which caused the resident anxiety, depression, and uncontrolled pain. […]

• Actual harm, isolatedF689Mar 19, 2024

  Based on observation, interview, and record review, the facility failed to protect the safety of one of three sampled residents (Resident 1), who were reviewed for falls and injuries, from a significant avoidable injury when Resident 1 had been evaluated to benefit from bed rails (rails attached to the bed to help with turning over in bed), and Resident 1 had requested bed rails that were never put on her bed. Certified Nursing Assistant (CNA) B told Resident 1 to roll over in bed so that she could change Resident 1 ' s brief (an adult protective underwear for loss of bowel and bladder control). […]

• Actual harm, isolatedF600Sep 28, 2023

  Based on observation, interview, and record review the facility failed to protect residents from abuse when: 1. One out of four sampled residents (Resident 1) had been struck in the face by another resident (Resident 2) when Resident 2 heard Resident 1 verbally abuse female staff members. 2. Two out seven sampled residents (Resident 6 and Resident 7) endured ongoing verbal abuse from Resident 1 during resident cigarette (smoke) breaks. This failure placed residents at an increased risk for inability to attain or maintain physical, mental, and psychosocial well-being and caused feelings of anxiety (feelings of worry, nervousness or unease, symptoms could include irritability or aggression) Findings: 1. […]