Oakwood Village East Health and Rehab Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Oct 22, 2025

  Based on observation, interview, and record review, the facility did not ensure each resident receives care consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) and each resident with PIs receives necessary treatment and services, consistent with professional SOP, to promote healing, prevent infection, and prevent new injuries from developing in 1 of 1 sampled residents (R2), out of a total sample of 3 residents reviewed.The facility inaccurately assessed R2's risk of skin breakdown.The facility failed to create a robust plan of care to prevent PI development.The facility failed to update R2's care plan timely with interventions to prevent worsening pressure injuries or prevent more injuries from developing.Staff inconsistently staged R2's wound and… […]

• Immediate jeopardy, isolatedF689Jun 28, 2021

  The facility did not ensure each resident received adequate supervision when 1 of 6 sampled residents (R1), who is dependent on staff, was left outside for over four hours on a hot day (real feel temperature of 95 degrees) without routine monitoring or staff awareness that the resident was outside. The failure to ensure that a system for checking on a dependent resident when they are outside or to alert oncoming staff a resident was outside resulted in a finding of Immediate Jeopardy. The Immediate Jeopardy began on 6/9/21. NHA (Nursing Home Administrator) A was notified of the Immediate Jeopardy on 6/16/21 at 3:26 PM. The Immediate Jeopardy was removed on 6/16/21. […]

• Actual harm, isolatedF684May 26, 2022

  Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring for change in condition for 1 resident (R1) of 3 residents reviewed for change of condition out of a total of 8 sampled residents. The facility did not recognize and notify the Physician of R1's repeated refusals of insulins. On 5/6/22 at approximately 1:35 AM, R1 complained of an upset stomach and vomited during a tube feeding. The facility did not recognize R1's stomach pain, nausea, and vomiting as a potential symptom of ketoacidosis. R1 presented with a significant change in physical status. […]

• Actual harm, isolatedF760May 26, 2022

  Based on interview and record review, the facility did not ensure residents are free of significant medication errors for 1 of 8 total sampled residents (R1). On 5/19/22 at 5:43 PM, a staff member accidentally marked R1's bedtime (HS) dose of insulin [MEDICATION(S)] sliding scale as Refused (Code 2) on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN D (Licensed Practical Nurse) reported R1's blood sugar to the RN E (Registered Nurse-agency). RN E stated to LPN D that she was going to take a break. RN E did not continue monitoring R1 or share this information with the oncoming night (NOC) shift staff. R1 was transferred to the hospital on 5/20/22 at 12:30 AM when his blood sugar read HIGH indicating it was over 600 and he was complaining of abdominal pain. […]

• No harm, potential for more than minimal, widespreadF880Jul 29, 2025

  Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 33 residents. One staff member returned to work too soon after experiencing GI (gastrointestinal) symptoms. Five staff members on the facility’s line list did not have the date of last symptoms listed. R63 and R13, did not have accurate symptoms reflected on the line listing. Staff did not perform appropriate hand hygiene per Standards of Practice while providing catheter care to R6. […]