Nhc Healthcare, Oakwood

Based on the facility's Work In/Out Report and interviews the facility failed to ensure there was Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, for 2 of 30 days reviewed. The facility's census was 51. The findings include: Review of the facility's Work In/Out Report for time punches dated 1/10/2026, revealed RN A worked from 12:00 AM until 12:45 AM and RN A and RN B worked from 7:00 PM until 12:00 AM, which provided a period of 5 hours of RN coverage, resulting in no RN coverage for 8 consecutive hours. The facility was unable to provide documentation of RN coverage between 12:46 AM and 6:59 PM, resulting in no consecutive 8 hour interval of RN coverage for 1/10/2026. Review of the facility's Work In/Out Report for time punches dated 1/11/2026, revealed RN A worked from 12:00 AM until 3:00 AM and 3:30 AM until 7:30 AM. RN B worked from 12:45 AM until 7:15 AM, and from 7:00 PM until 12:00 AM, which provided a period of 7.5 hours of RN coverage, resulting in no RN coverage for 8 consecutive hours. The facility was unable to provide documentation of RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to provide care and services to promote dignity for 1 of 1 (Resident #39) sampled residents reviewed for indwelling urinary catheter (plastic tube inserted into the bladder to drain urine).The findings include: 1. Review of the facility policy titled, Patient Rights, dated 9/2024, revealed .Privacy.we provide you with privacy so that you may maintain a dignified existence, self-determination. 2. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses including Aphasia, Obstructive and Reflux Uropathy (a condition that prevents normal urine flow), and Hypertensive Heart and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #39 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #39 was severely cognitively impaired, and was coded for the use of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, admission and financial agreement review, resident trust fund account review, medical record review, and interview, the facility failed to refund the resident's funds within 30 days of death or discharge for 3 of 3 (Resident #64, #65, and #66) sampled residents reviewed for personal funds. The findings include: 1. Review of the facility policy titled, Patient Trust, dated 10/2010, revealed .The funds should be refunded within 30 days of death or discharge, unless the state guidelines specify a shorter time frame. Review of the facility's admission and Financial Agreement revealed .Monies held for a Patient in trust will be paid to Patient's estate within 30 days of death. 2. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Dementia, Adult Failure to Thrive, Depression, and Anxiety. Review of Resident #64's face sheet listed Family Member A as the Resident Representative. Review of the Nurse's Note dated [DATE], revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, medical record review, observation and interview the facility failed to follow the facility accident policy related to an unobserved fall for 1 of 3 (Resident #31) reviewed for accidents. The findings include: 1. Review of the facility policy titled, INCIDENT AND ACCIDENT PROCESS, with revision date of 8/13/2013 revealed, .Investigation into the incident/accident .Obtain information on what happened-what was actually seen or heard. If not witness, get patient's statement about what happened .Never move the patient until the assessment is completed unless immediate treatment is needed .Assess the patient related to the incident/accident . 2. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction, Monocular Vision Loss and Personal history of Traumatic Brain Injury. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #31 had a Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interviews, the facility failed to ensure that 1 of 24 sampled residents (Resident #31) received trauma-informed care in accordance with professional standards of practice and accounting for a resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. The findings include: 1. Review of the undated facility policy titled, Care Plan Completion, revealed, .After completing the MDS [Minimum Data Set] and CAA [Care Area Assessment] portions of the comprehensive assessment, the next step is to evaluate the information gained through both assessment processes to identify problems .patient's .problems, and needs . Review of the undated facility policy titled, Trauma Informed Care, revealed, .As an organization we are committed to learning about trauma and its effects and to engage with an implement trauma-informed approaches to the care we provide and the culture we create .Trauma-informed care is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection was maintained for 1 of 1 sampled resident (Resident #16) reviewed for enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Enhanced Barrier Precautions, dated 4/2024, revealed .Enhanced Barrier Precautions (EPB) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact activities. EPB are used in conjunction with standard precautions and expand the use of PPE [personal protective equipment] to donning of gown and gloves during high-contact patient care activities that provide opportunities for transfer of MDRO to staff hands and clothing .EPB are indicated for patients with .wounds .even if the patient is not known to be infected or colonized with a MDRO .Providers and partners must wear gloves…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, documentation review, and interview, the facility failed to ensure there was no more than 14 hours between a substantial evening meal and breakfast the following day. The findings include: Review of facility's policy titled, Meal Service & Patient Meal Delivery, dated 11/2020, revealed, .The center will provide meals with no greater than a 14-hour lapse between the evening meal and breakfast (or 16 hours with approval of a resident group and provision of a substantial snack) . Review of the undated facility documentation titled, Meal Service Schedule, revealed 15 hours between the evening meal at 4:00 PM and the breakfast meal at 7:00 AM. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness and End Stage Renal Disease. Review of Resident #2's Quarterly Minimum Data Set assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 15 indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, observations, and interviews, the facility failed to ensure food was served in a sanitary manner for 46 of 47 residents served a meal tray from the kitchen. The findings include: Review of the facility's policy titled, Glove Use, revised 11/2017, revealed, .Change gloves before moving from one task to another .partners shall have no bare hand contact with food and shall use appropriate items such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment when handling food .Gloves should never replace the use of utensils, tongs, etc . Observation in the kitchen on 3/7/2022 at 11:10 AM, revealed the [NAME] was preparing meals on the tray line, reached into the warmer and touched a roll with her gloved hand, then touched French fries with her gloved hand and placed them on a resident meal plate. During an interview on 3/7/2022 at 11:10 AM, the [NAME] confirmed she should not have touched the roll or the French fries with her gloved hand. During an interview on 3/7/2022 at 11:15 AM, the Certified Dietary Manager (CDM) confirmed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to complete a Care Conference after each completed resident assessment for 9 of 27 sampled residents (Residents #2, #3, #6, #16, #21, #23, #39, #41, and #42) reviewed. The facility also failed to revise a Care Plan for 1 of 27 sampled residents (Resident #23) reviewed. The findings include: Review of the facility policy titled, Updating and Revising Care Plans, dated [DATE], revealed, .Routine Reviews and Updates: Care plans are updated as needed but are reviewed completely by the interdisciplinary team on a quarterly basis within 7 days of the completion of the clinical MDS [Minimum Data Set] assessment . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Nontraumatic Intracranial Hemorrhage, End Stage Renal Disease, Dependence on Renal Dialysis, Major Depressive Disorder, Epilepsy, Hypertensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 17 residents (Resident #9 and Resident #35) were treated in a dignified manner during the lunch meal on 3/7/2022. The findings include: Review of the facility's policy titled, Resident Rights, dated 2/2020, revealed, .we support the patient/resident's right to live in an environment which is individualized for them. We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services, by honoring and supporting each patient/resident's preferences, choices, values and beliefs . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Senile Degeneration of Brain, Dementia, and Dysphagia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #9 required total assistance with one person assist with eating. Review of the medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to develop and implement a Baseline Care Plan within 48 hours of admission for 3 of 7 sampled residents (Residents #1, #97, and #146) reviewed. The findings include: Review of the facility policy titled, Patient Care Plans, updated 10/2021, revealed, .The center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care. Patient's goals for care and preferences will be determined and used to develop their plan of care .Time Frames for Care Plans: Baseline plan of care within 48 hours of admission addressing the immediate needs of the patient. Must be presented to patient and/or patient representative in terms they can understand .All disciplines involved in the care of the patient must be represented in the baseline care plan and be included in the development . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observation, and interview, the facility failed to sanitize medical equipment after usage for 3 of 27 sampled residents (Resident #13, #26, and #97) observed. The findings include: Review of the facility's undated policy titled, Cleaning of Shared Medical Equipment, revealed, .Equipment: All durable medical equipment and reusable items including but not limited to: stethoscopes, blood pressure cuffs, thermometers, oximeters, and glucometers .Durable medical equipment (DME) must be cleaned and disinfected before reuse by another patient . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Spastic Quadraplegic Cerebral Palsy. Review of the current Physician Orders for Resident #13 dated 3/1/2022, revealed, .Droplet Precautions. DX COVID 19 . Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses which included Unspecified Atrial Fibrillation.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.