Oakwood Healthcare & Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 25, 2022

  Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: During the initial tour of the main kitchen on February 22, 2022 at 10:30 a.m. where foods and fluids were stored, prepared and distributed it was observed that the mechanical dish machine was not functioning. The Director of Dietary Services, Employee E10 reported that the hot water heater that supplies water for the machine to sanitize and clean the dishes, utencils, cups, bowls, pots and pans was out of service. […]

• No harm, potential for more than minimal, patternF812May 7, 2026

  Based on review of food safety standards, observations, and staff interview it was determined that the facility failed to ensure beverages were stored in accordance with standards for food service safety.Findings Include: Review of Refrigeration & Food Safety guidelines by the United States Department of Agriculture (USDA), Food Safety and Inspection Service, revealed cold food should be kept at or below 40 degrees Fahrenheit (F). Further review of guidelines by the USDA revealed the danger zone is defined as temperatures between 40 and 140 degrees F where bacteria grow most rapidly. A tour of the main kitchen conducted on May 4, 2026, at 9:30 a.m. […]

• No harm, potential for more than minimal, patternF725Aug 29, 2024

  Based on review of staffing schedules, facility documentation, and staff interview, it was determined that the facility failed to ensure sufficient nursing staff to assure residents attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 26 residents reviewed (Residents R78, R100, R32). Findings include: A review of the clinical record revealed Resident 78 was admitted to the facility on [DATE]. Review of Quarterly Minimum Data Set (MDS-a periodic assessment of care needs) dated August 222, 2024, indicated that the Brief Interview for Mental Status (BIMS) score of 14-cognition intact On August 26, 2024, at 10:40 a.m., an interview was conducted with Resident R78, who expressed feeling very upset and began crying. […]

• No harm, potential for more than minimal, patternF561May 30, 2024

  Based on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that the resident had the right to choose healthcare and providers of healthcare consistent with resident's interests and plan of care for one of three residents reviewed. (Resident R1) Findings Include: Interview with Resident R1 on May 30, 2024, at 10:00 a.m. stated he did not want Employee E4, Licensed Nurse, to provide care for him. He stated after the last survey by the State Survey Agency in September 2023, he did not want her to provide him care and administer medications. Resident also stated she made mistakes with his medication administration, and he was told by the facility staff that Employee E3 would not administer him his medications. […]

• No harm, potential for more than minimal, patternF684Nov 9, 2023

  Based on review of clinical records, review of facility policy, interview with resident and staff, it was determined that facility did not provide needed care and services in accordance with professional standards of practice related to administering blood pressure medication outside of physician ordered parameters for two out of seven residents reviewed (Resident R48 and R380) Findings include: Review of facility's policy 'Vital Signs', revised on March 1st, 2017, states the following: blood pressures that are taken in conjunction with antihypertensive meds should be documented as per facility guidelines. […]