Oakwood Specialty Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF695Jan 31, 2023

  Based on clinical record review, family and staff interviews and facility policy review, the facility failed to assure that staff provided appropriate tracheostomy care to include the assessment of respiratory failure and failed to provide appropriate training to nursing staff on procedures during an accidental extubation (tracheostomy tube fall out), tracheostomy care and suctioning for 1 of 1 resident (Resident #12). This failure resulted in the transport by MedAir to a hospital and placed on mechanical ventilation therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. The facility identified a census of 36 residents. […]

• Immediate jeopardy, isolatedF698May 9, 2022

  Based on clinical record review, staff interview, and policy review, the facility failed to provide care and services for an insulin/[CONDITION(S)] dependent resident in accordance with professional standards of care for 1 of 1 insulin/[CONDITION(S)] dependents residents reviewed (Resident #21). The facility failed to thoroughly review the resident's hospital discharge summary and orders upon admission on 4/14/22, to meet the resident's needs. The resident failed to receive insulin for a day and a half and missed a [CONDITION(S)] treatment on 4/15/22 due to a lack of transportation. The resident experienced diabetic ketoascidosis (a serious diabetes complication) and transferred to the Emergency Department with a blood glucose reading in the 1000 range. […]

• Actual harm, isolatedF600Jan 31, 2023

  Based on observation, clinical record review, policy review, staff interview, and resident interview, the the facility failed to ensure 1 of 4 residents was free from abuse(Resident #4). The facility reported a census of 36 residents. Findings Include: 1. The Quarterly Minimum Data Set (MDS) assessment tool, dated 12/30/22, listed diagnoses for Resident #4 which included diabetes, pain in the right knee, and chronic pain syndrome. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene, extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use, and depended completely on 1 staff for bathing. The MDS listed the resident's BIMS(Brief Interview for Mental Status) score as 12 out of 15, which indicated moderately intact cognition. […]

• Actual harm, isolatedF684Oct 27, 2022

  Based on clinical record review, policy review, resident, family and staff interviews, the facility failed to appropriately provided assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well- being. Clinical record review revealed the nursing staff did not provide thorough follow-up assessments, update the resident's physician with the significant changes or provide treatment for 3 of 3 residents reviewed (Resident #9, #11, #23). The facility reported a census of 41. Findings Include 1. The Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Oct 27, 2022

  Based on observation, clinical record review, and staff interviews, the facility failed to provide appropriate supervision to ensure each resident ' s individual safety for 2 of 2 residents reviewed (Resident #11 & # 21). The facility reported a census of 41 residents. Findings Include: 1. The Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #11 revealed the diagnoses of high blood pressure, Alzheimer's, anxiety and [CONDITION(S)] in both knees. The MDS indicated that the resident required extensive assistance of 2 staff for bed mobility, dressing, toileting and transfers. Resident #11's Brief Interview for Mental Status (BIMS) was 00, which indicated severe cognitive impairment. […]