The Oaks at Woodfield

In the surveyor’s words

From the most serious findings on record at The Oaks at Woodfield, in the surveyor’s own words.

• Actual harm, isolatedF686Feb 17, 2023

  This Citation pertains to Intake Numbers MI00130541 and MI00131538. Based on observation, interview and record review, the facility failed to properly identify, monitor, and treat a skin condition for one resident (Resident #5) of three residents reviewed for pressure injury, resulting in the worsening and declining of the pressure ulcer, wound infection, resident suffering hospitalization and surgical wound debridement. Past Non-Compliance was given for this citation with a Compliance Date of 12/16/2022. […]

• Actual harm, isolatedF600May 14, 2021

  This Citation pertains to Intake Number MI 739. Based on observation, interview and record review, the facility failed to prevent physical and verbal staff-to-resident abuse for one resident (Resident #1) of seven residents reviewed for abuse resulting in Resident #1 experiencing rough care, verbal and aggressive behavior from the staff, restrained and feeling choked when staff hugged the resident and feeling fearful, distraught and yelling out for help during the altercation. Findings include: On 5/7/21 at 1:58 PM, an observation was made of Resident #1 in their room in a wheelchair. The Resident was dressed, clean and was propelling the wheelchair on their own. The Resident was wearing a boot on one leg and foot. […]

• Actual harm, isolatedF686May 14, 2021

  This Citation Pertains to Intake Numbers: MI 756 and MI 055. Based on interview and record review, the facility failed to ensure pressure ulcers were assessed, monitored, wound care provided and appropriate interventions were in place for two residents (Residents #4 and Resident #5) of five residents reviewed for pressure ulcers, resulting in Resident #4 developing 2 Deep Tissue Injuries - facility-acquired pressure ulcers: 1 on each heel and Resident #5 developing a Stage III facility-acquired pressure ulcer on the coccyx and 2 Deep Tissue Injuries-facility acquired pressure ulcers, one on each heel. […]

• No harm, potential for more than minimal, widespreadF812May 25, 2023

  Based on observation, interview and record review, the facility failed to ensure that sanitary conditions existed in the kitchen and that cookware, storage areas, and serving items were free of debris and allowed to air dry, dispose of expired food items, ensure food products were properly labeled with open and used by dates, cover food items stored in refrigerator, and document food temperatures logs, resulting in the potential contamination of food, bacterial harborage and the increased potential for food borne illness. This deficient practice had the potential to affect all residents that consume food prepared in the kitchen of a census of 60 residents. Findings include: On [DATE] at 9:50 AM, an initial tour of the kitchen was conducted with Cook H. […]

• No harm, potential for more than minimal, patternF550Jun 10, 2026

  Based on observation, interview, and record review, the facility failed to ensure that 1) Call lights were answered in a timely manner, 2) Residents' preferences were respected, and 3) Residents were treated with dignity during the provision of care for one resident (Resident #28) and a confidential group of residents reviewed for dignity with care. Findings include: During the Facility's Monthly Resident Council Meeting held on 6/8/26 at 3:15 PM, twelve (12) residents of a confidential group of residents were present. At the meeting, the council raised the call light response time as an issue. They indicated that it has been an ongoing concern. Ten (10) confidential group of residents raised their hands when asked about the wait time experienced when they activated their call button. […]