Oakwood SNF LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF626Apr 8, 2022

  Based on administrative record review and interviews with the facility staff, it was determined that the facility failed to permit a resident to return to the facility after being transferred to the hospital by emergency petition for threats to self and others. According to Resident #5's medical record, the facility did not accurately evaluate the resident, rather they used the resident's status prior to transfer as the basis to refuse to accept the resident back into the facility. This was found to be evident for 1 of 7 residents reviewed for transfers during a complaint survey conducted at the facility (Resident # 5). […]

• Actual harm, isolatedF600Oct 21, 2024

  Based on resident interview, staff interview, clinical record review, and a review of the facility investigation of intake #MD00207612, it was determined that the facility staff failed to ensure residents were free from abuse. This was evident for 1 (#97) out of 6 residents reviewed for abuse. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Actual Harm Past Non-compliance (PNC). The findings include: This surveyor started an investigation into intake #MD00207612 on 10/2/24. It was revealed that on 7/12/24 at 8:30 AM, Geriatric Nursing Assistant (GNA) #8 was providing AM care to Resident #97 but the resident was resisting her. She asked GNA #9 for assistance. […]

• Actual harm, isolatedF600Apr 8, 2022

  Based on medical record review, interview with facility staff and residents, it was determined that the facility failed to protect Resident #8, from Resident #5 who has documented verbal aggression towards others. This failure led to the emotional degradation and potential psychosocial harm of Resident #5. This was evident during the review of a complaint and 1 of 2 roommates (#8) for Resident #5. The findings include: Review of the medical record for Resident #5 on 4/6/2022 at 9:25 AM revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/2022 Resident #8 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF578Mar 3, 2026

  Based on interviews and record reviews, it was determined that the facility failed to ensure residents were offered the opportunity to formulate Advanced Directives. This was found to be evident for 6 (#1, #2, #90, #11, #7, & #8) out of 7 residents reviewed for Advanced Directives planning during the recertification survey. The findings include:1) On 02/25/2026 at 9:17 AM, the surveyor requested the Director of Social Services provide documentation that Residents #1, #2, and #90 were provided opportunities to formulate Advanced Directives. On 02/25/2026 at 11:58 AM, The Director of Social Services stated that he was unable to find documentation that Advance Directives were offered to Residents #1, #2 and #90. 2) On 2/24/26 at 1:50 PM, the surveyor reviewed Resident #11's medical record. […]

• No harm, potential for more than minimal, patternF628Mar 3, 2026

  Based on record review and staff interview, it was determined that the facility failed to ensure notice of resident transfers and discharges were submitted to the representative of the Office of the State Long Term Care Ombudsman. This deficient practice was identified during annual survey and had the potential to affect all residents who experienced a transfer or discharge.The findings include:On 02/27/2026 at 9:40 AM, during an interview with the Administrator, the surveyor requested documentation indicating that the Ombudsman has been notified of monthly transfers and discharges between October 2025 to December 2025. […]