Oakwood Rehab and Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 27, 2026

  Based on observation, interview, and record review, the facility failed to provide supervision for a resident (R2) to prevent a fall. This resulted in R2 obtaining a fracture to her right clavicle. This applies to 1 of 3 residents reviewed for safety and supervision in the sample of 6.The findings include:R2's electronic face sheet dated 4/26/26 showed R2 has diagnoses including but not limited to chronic obstructive pulmonary disease, type 2 diabetes, heart failure, depression, muscle wasting and atrophy, and osteoporosis.R2's facility assessment dated [DATE] showed R2 has moderate cognitive impairment.R2's care plan dated 10/14/25 showed, (R2) is at risk for falls related to general weakness, overestimates abilities, poor coordination, unsteady gait, use of narcotics, decreased safety… […]

• Actual harm, isolatedF600Dec 12, 2024

  Based on observation, interview, and record review, the facility failed to ensure a resident was free from verbal and physical abuse. This applies to 1 of 3 residents (R73) reviewed for abuse allegations in the sample of 18. This failure resulted in R73 feeling traumatized, unsafe, being afraid to sleep, and developing insomnia. The findings include: R73's face sheet showed him to be a [AGE] year old male admitted to the facility on [DATE], with diagnoses that include Necrotizing Fasciitis, Severe sepsis, Pneumonia, Acute respiratory failure, Alcohol Abuse, and Long Term use of antibiotic. R73's Minimum Data Set (MDS) dated [DATE], showed R73 to be cognitively intact. […]

• Actual harm, isolatedF686Sep 4, 2024

  Based on observation, interview, and record review the facility failed to perform skin assessments in order to prevent pressure injuries from developing for 1 of 5 residents (R2) reviewed for pressure in the sample of 6. This failure resulted in R2 developing a facility acquired pressure injury that was not identified until it was a Stage 3. The findings include: On 9/3/24 at 11:50 AM, R2 was dressed and sitting bedside in his room. R2 had a low air loss mattress on his bed. R2 said he has a pelvic fracture in two places which causes him some pain. R2 said he is able to walk with a walker, move in bed, and takes himself to the bathroom. R2 said he got the low air loss mattress when they found a sore on his bottom. R2 said he didn't have any sores when he came in. […]

• Actual harm, isolatedF600Apr 30, 2024

  Based on observation, interview, and record review the facility failed to ensure a resident (R1) was free of physical abuse from another resident (R2) for 2 of 3 residents reviewed for abuse in the sample of 3. This failure resulted in R2 entering R1's room and hitting R1 over the volume of a TV. R1 sustained multiple facial injuries; abrasions to the left hand and ear; and required evaluation and treatment in the emergency room . The findings include: On 4/23/24 at 12:04 PM, R1's frail body was tilted to the right to watch the TV. R1's entire face was covered with bruises of various colors and stages of healing. R1 had a golf ball sized hematoma (blood filled lump) near his left cheek and eye. R1 had a dressing to the left side of his nose. […]

• Actual harm, isolatedF689Oct 23, 2022

  Based on observation, interview and record review, the facility failed to provide safety measures during transfer, bed mobility and incontinence care to a resident that is at high risk for fracture. This failure resulted in R1 sustaining a displaced, spiral fracture of the left lower leg. This applies to 1 of 3 residents (R1) reviewed for ADL (Activities of Daily Living) care. The findings include: The EMR (Electronic Medical Record) shows that R1, an [AGE] year-old, was admitted to the facility on [DATE]. […]