Inspection Reports for
The Oaks at Woodfield
5370 Baldwin Rd., Grand Blanc, MI, 48439
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 8, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of the nursing home to assess compliance with regulatory requirements, including care planning, activities of daily living, hospice services, nutrition, dialysis services, and medication storage.
Findings
The facility was found deficient in developing comprehensive, person-centered care plans for residents, ensuring timely and preference-based activities of daily living, maintaining hospice documentation in medical records, monitoring resident weights as ordered, providing transportation for dialysis, and securing medication storage with proper labeling and expiration monitoring.
Deficiencies (6)
F 0656: The facility failed to develop and implement complete care plans reflecting residents' specific preferences for code status for 4 of 16 residents reviewed.
F 0677: The facility failed to provide timely activities of daily living, including showers and nail care, consistent with resident preferences for 3 of 4 residents reviewed.
F 0684: The facility failed to ensure hospice records and communication were part of the medical record for 2 residents receiving hospice services.
F 0692: The facility failed to obtain and monitor resident weights as ordered for 2 of 3 residents reviewed for nutrition.
F 0698: The facility failed to inform and offer transportation for dialysis appointments to one resident, resulting in family arranging transport.
F 0761: The facility failed to ensure safe and secure medication storage, including unlocked medication rooms accessible to nurse aides, unlabeled and expired glucose control solutions, and unsecured treatment cart keys.
Report Facts
Residents reviewed for care plans: 16
Residents affected by care plan deficiency: 4
Residents reviewed for ADL care: 4
Residents affected by ADL deficiency: 3
Residents reviewed for hospice services: 2
Residents reviewed for nutrition: 3
Residents affected by nutrition deficiency: 2
Dialysis sessions documented: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services staff K | Interviewed about process for obtaining residents' code status preferences | |
| MDS Coordinator L | Interviewed about residents' care plans for code status preferences | |
| Regional Clinical Coordinator Nurse B | Interviewed about care plan and air mattress settings for Resident #45 | |
| Assistant Director of Nursing (ADON) C | Interviewed about hospice binder and documentation for Resident #47 | |
| Corporate Nurse B | Observed and assisted with resident repositioning and nail care | |
| Registered Dietitian RD J | Interviewed about weight monitoring and dietary recommendations | |
| Licensed Practical Nurse (LPN) AW | Provided information about dialysis transportation for Resident #55 | |
| Social Services Director #1 | Interviewed about dialysis transportation services and bundled payment | |
| Administrator | Interviewed about dialysis transportation and family communication | |
| Nurse H | Observed allowing nurse aides access to medication room and medication administration | |
| Nurse G | Observed medication storage and labeling issues | |
| Nurse Supervisor I | Interviewed about nurse aides access to medication room | |
| Regional Clinical Coordinator RCC Nurse B | Interviewed about glucose monitoring solutions | |
| Director of Nursing (DON) | Interviewed about treatment cart key storage |
Inspection Report
Renewal
Census: 20
Capacity: 38
Deficiencies: 0
Date: Sep 25, 2024
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for The Oaks at Woodfield facility.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities. Renewal of the license is recommended.
Report Facts
Number of staff interviewed and/or observed: 10
Number of residents interviewed and/or observed: 20
Capacity: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Glynn | Administrator/Authorized Representative | Named as Administrator/Authorized Representative of the facility |
| Aaron Clum | Licensing Staff | Licensing Consultant who signed the report |
Inspection Report
Complaint Investigation
Capacity: 38
Deficiencies: 1
Date: Jun 10, 2024
Visit Reason
The inspection was conducted in response to a complaint alleging that Resident A lacked protection at the facility.
Complaint Details
The complaint alleged Resident A was short of breath, had increased confusion due to overmedication, was told to urinate in her clothing, and that the facility did not answer calls from a relative. The allegation that Resident A lacked protection was not substantiated.
Findings
The investigation found insufficient evidence to support the allegation that Resident A lacked protection. However, a violation was established for failure to update Resident A's service plan annually or after a significant change in care needs.
Deficiencies (1)
Failure to update Resident A's service plan at least annually or after a significant change in care needs.
Report Facts
Capacity: 38
Complaint Receipt Date: May 23, 2024
Investigation Initiation Date: May 24, 2024
Report Due Date: Jul 22, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Glynn | Authorized Representative/Administrator | Named as facility representative and involved in communication during investigation |
| Jessica Rogers | Licensing Staff | Conducted the investigation and authored the report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
| Employee #1 | Staff member who administered Resident A's medications on 6/25/2023; training and employment eligibility reviewed |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2024
Visit Reason
The inspection was conducted based on complaint intake MI00142646 regarding failure to ensure timely dressing changes for residents, resulting in missed dressing changes and potential worsening wounds.
Complaint Details
The complaint alleged that Resident #5's wound dressing was not changed for 10 days, with blood leakage and drainage present. The complaint was substantiated based on observation, interviews, and record review.
Findings
The facility failed to provide timely dressing changes for two residents, Resident #117 and Resident #5, leading to missed dressing changes and potential wound worsening. Resident #117's wound drain dressing was not labeled or dated, and Resident #5 had a dressing that was not changed as ordered, with drainage and signs of infection.
Deficiencies (2)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences. Resident #117's abdominal wound drain dressing was not labeled or dated, and there was no specific treatment order for monitoring or changing the dressing.
F 0684: Resident #5 had a skin tear dressing dated 4/7 that was not changed for 10 days, despite an order to change every five days. The dressing had blood leakage and purulent drainage, indicating inadequate wound care.
Report Facts
Residents reviewed for wounds: 4
Days dressing not changed: 10
Dressing change frequency order: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding Resident #5's wound dressing change and acknowledged nursing error | |
| Infection Control Nurse L | Examined Resident #117's wound drain dressing and confirmed lack of labeling and dating |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: May 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to complete baseline care plans within 48 hours of admission, inadequate wound care and dressing changes, insufficient supervision leading to resident falls and injuries, failure to monitor and address significant weight loss, and delayed response to pharmacy medication recommendations.
Deficiencies (5)
F0655: The facility failed to ensure baseline care plans were completed within 48 hours of admission for two residents, resulting in incomplete care plans and unmet care needs.
F0684: The facility failed to provide appropriate treatment and care for wounds, including untimely dressing changes and lack of specific wound drain care orders for two residents.
F0689: The facility failed to provide adequate supervision and interventions to prevent falls, resulting in a resident sustaining a hip fracture and another resident experiencing multiple falls.
F0692: The facility failed to monitor and address significant weight loss for one resident, including lack of updated nutritional interventions and failure to notify the registered dietician.
F0756: The facility failed to ensure timely review and physician response to pharmacy medication recommendations, resulting in a resident continuing to receive a medication with potential adverse effects contributing to falls.
Report Facts
Weight loss percentage: 5.1
Fall dates: 4
Pharmacy recommendations dates: 2
Baseline care plan completion time: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse D | Nurse | Interviewed regarding Resident #40's admission assessment and care plan completion. |
| Nurse L | Infection Control Nurse | Examined wound dressing and respiratory treatment apparatus for Resident #117. |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care, pharmacy recommendations, weight loss monitoring, and fall prevention. |
| Nurse C | Nurse | Cared for Resident #52 during fall incident and provided details about supervision. |
| Pharmacist B | Pharmacist | Provided pharmacy medication recommendations for Resident #15. |
| RD J | Registered Dietician | Interviewed regarding weight loss monitoring and care plan updates for Resident #52. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 9, 2023
Visit Reason
The investigation was conducted due to a complaint regarding narcotic diversion by a nurse at the facility, involving misappropriation of a resident's medication and inaccurate narcotic reconciliation and documentation.
Complaint Details
The complaint investigation substantiated that Nurse A diverted Resident #801's liquid morphine, resulting in an overdose. The facility's narcotic reconciliation and documentation were found inaccurate for multiple residents, with improper wasting and discrepancies in medication records.
Findings
The facility failed to prevent narcotic diversion by Nurse A, who admitted to an unintentional overdose of a resident's liquid morphine. Additionally, the facility failed to maintain accurate reconciliation and documentation of narcotic administration for multiple residents, resulting in discrepancies and improper wasting of medications.
Deficiencies (2)
F 0602: The facility failed to protect residents from misappropriation of property when Nurse A diverted Resident #801's liquid morphine, resulting in an unintentional overdose and hospitalization of Nurse A.
F 0755: The facility failed to provide accurate pharmaceutical services by not completing proper reconciliation, documentation, and wasting of narcotics for Residents #802, #804, and #805, leading to discrepancies in narcotic administration records.
Report Facts
Residents reviewed for narcotic diversion: 5
Narcotic doses discrepancy: 9
Narcotic doses discrepancy: 8
Narcotic doses discrepancy: 3
Morphine remaining: 14.75
Morphine remaining: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Registered Nurse | Admitted to narcotic diversion and unintentional overdose on Resident #801's morphine; terminated for gross misconduct |
| Scheduler G | Assisted in transporting Nurse A to emergency room and provided interview regarding incident | |
| Manager N | Weekend Nurse Manager | Observed Nurse A's condition deteriorate and assisted in transporting her to emergency room |
| Nurse C | Witnessed Nurse A waste narcotic without proper documentation and reported discrepancies in narcotic administration | |
| Coordinator E | AP/Payroll Coordinator | Interviewed regarding facility hiring practices and communication with Nurse A post-incident |
| Administrator | Interviewed regarding narcotic diversion incident and facility response | |
| DON | Director of Nursing | Interviewed regarding narcotic diversion incident and facility response |
| Corporate Clinical Support D | Interviewed regarding narcotic diversion incident and facility response |
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 31, 2023
Visit Reason
The document serves as a notification that the Home for the Aged license for The Oaks at Woodfield has been renewed for a 12-month period effective 09/10/2023.
Findings
The license renewal confirms compliance with licensing requirements allowing the facility to continue operation at the specified address.
Report Facts
License effective period: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Clum | Licensing Staff | Author of the license renewal notification |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 25, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide written notices of transfer and bed hold to the responsible party for one resident.
Complaint Details
The complaint pertained to Intake Number MI00135785 and involved failure to provide written notices of transfer and bed hold to the responsible party for Resident #161. The complaint was substantiated based on interviews and record review.
Findings
The facility failed to provide a written notice of transfer and bed hold policy to the responsible party for Resident #161, resulting in the responsible party being uninformed of the transfer and bed hold rights. The resident was transferred to the hospital on 4/8/23, and upon release on 4/15/23, the facility was full and could not admit the resident back.
Deficiencies (2)
F 0623: The facility failed to provide a written notice of transfer to the responsible party for one resident, resulting in the potential for the responsible party to be uninformed of the transfer and appeal rights.
F 0625: The facility failed to provide a written notice of bed hold upon transfer to the responsible party for one resident, resulting in the responsible party being uninformed of the facility's bed hold policy.
Report Facts
Assessment Reference Date: Apr 8, 2023
BIMS Score: 15
Transfer Date: Apr 8, 2023
Release Date: Apr 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Customer Service Specialist | Reported no written notices of transfer or bed hold sent to responsible parties | |
| Community Service Representative | Reported no written notices of transfer or bed hold sent to responsible parties | |
| Business Office Manager | Reported never sending written notices for transfer or bed hold | |
| Registered Nurse | Completed Notice of Transfer or discharge and notified guardian via telephone | |
| Nursing Home Administrator | Reported facility could not admit resident due to full beds |
Inspection Report
Routine
Deficiencies: 6
Date: May 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, transfer and discharge notifications, respiratory care, medication administration, and food safety in the nursing home.
Findings
The facility was found deficient in ensuring accurate completion of advance directives, providing timely written notices of transfer and bed hold to responsible parties, maintaining clean respiratory equipment and proper CPAP use, following physician orders for medication administration, and maintaining sanitary food storage and preparation conditions.
Deficiencies (6)
F 0578: The facility failed to ensure accurate completion of advance directive information for one resident, resulting in potential non-adherence to resident medical care preferences.
F 0623: The facility failed to provide a written notice of transfer to the responsible party for one resident, resulting in potential uninformed transfer and appeal rights.
F 0625: The facility failed to provide a written notice of bed hold upon transfer to the responsible party for one resident, resulting in uninformed bed hold policy and alternate placement.
F 0695: The facility failed to ensure nebulizer equipment was clean and dry, initiate physician orders and treatment plans for CPAP use, resulting in potential untreated sleep apnea and respiratory infections for two residents.
F 0757: The facility failed to follow a physician's order to remove a lidocaine patch for one resident, resulting in extended exposure with potential for skin breakdown and adverse reactions.
F 0812: The facility failed to maintain sanitary kitchen conditions, properly label and cover food items, and document food temperature logs, increasing the risk of food contamination and foodborne illness.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 60
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