Inspection Reports for
The Oaks at Woodfield

R 325.1922 Admission and retention of residents: the home failed to update Resident A's service plan annually or after a significant change in care needs, as the plan dated 3/1/2022 did not reflect her increased care requirements before discharge on 7/5/2023.

The facility failed to develop person-centered, comprehensive care plans reflecting residents' specific code status preferences for multiple residents.

The facility failed to provide timely and preferred bathing and grooming care for residents, resulting in missed showers, long toenails, and unshaved facial hair.

The facility failed to ensure hospice records and communication were part of the medical record for residents receiving hospice services.

The facility failed to ensure weights were obtained, monitored, and recorded as ordered, resulting in inconsistent weight monitoring for residents.

The facility failed to provide transportation to and from dialysis appointments as a covered service, requiring family members to arrange transport.

The facility failed to ensure safe and secure medication storage, including allowing nurse aides to access medication rooms unattended, unlocked medication refrigerators containing insulin pens and vaccines, expired glucose control solutions without open dates, unlabeled backup medications, and unsecured treatment cart keys left on the cart.

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to ensure baseline care plans were completed within 48 hours of admission for two residents, resulting in incomplete baseline care plans and unmet care needs.

F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to ensure timely dressing changes and proper wound care for two residents, resulting in missed dressing changes and potential for worsening wounds.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision and interventions to prevent falls for two residents, resulting in a fall with fracture and multiple falls with injuries.

F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to monitor and address significant weight loss for one resident, did not notify the registered dietician timely, and did not update nutritional interventions accordingly.

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines: the facility failed to ensure timely physician response to pharmacy medication recommendations for one resident, resulting in continued use of a medication with potential adverse effects including falls.

F 0602 Protect each resident from the wrongful use of the resident's belongings or money: Nurse A diverted Resident #801's liquid morphine resulting in an unintentional overdose requiring emergency medical treatment and intubation.

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: The facility failed to complete accurate reconciliation, documentation, and wasting of narcotics for Residents #802, #804, and #805, resulting in discrepancies between the Medication Administration Record and Controlled Use Record.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: 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 a transfer and appeal rights.

F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: 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.

F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to ensure accurate completion of advance directive information for one resident (Resident #29), including illegible signatures and missing Durable Power of Attorney paperwork.

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights: the facility failed to provide a written notice of transfer to the responsible party for one resident (Resident #161).

F 0625 Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide a written notice of bed hold upon transfer to the responsible party for one resident (Resident #161).

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to ensure nebulizer equipment was maintained clean and dry, and failed to initiate and enact physician orders and treatment plans for CPAP use for two residents (Residents #13 and #19), resulting in lack of CPAP use and potential respiratory complications.

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs: the facility failed to follow a physician's order to remove a lidocaine patch for one resident (Resident #19), resulting in extended exposure to lidocaine and potential for skin breakdown and adverse reactions.

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain sanitary conditions in the kitchen, including dirty ice cream scoop containers, uncovered and undated food items, dirty cookware and trays, and incomplete documentation of food and equipment temperatures, increasing the risk of foodborne illness for all residents.