The Oaks at Woodfield

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interviews, and record review, the facility 1) Failed to ensure that medications and related supplies were properly labeled, stored, and discarded upon expiration and, 2) Failed to secure chemical medication destroyers, chemical sanitation cloths, and alcohol based hand rubs out of residents' reach. These deficiencies were identified in two of two medication carts, one of two medication rooms, and in three of three resident units reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in allowing waterborne pathogens to exist and spread in the facility's plumbing system with an increased risk of respiratory infection among all residents in the facility.

Inspectors wroteThis citation pertains to Intake Number 3011265. Based on interview and record review, the facility failed to ensure an appropriate, complete and thorough investigation was conducted for one (1) resident (Resident #77) of 3 residents reviewed for discharges when Resident #77 became unresponsive while receiving a shower done by a family member with unknown training for performing safe Activities of Daily Living (ADL) and no other nursing staff member was present to witness the unusual event resulting in R77 hitting her head on the grab bar, exhibiting a significant change in condition during the shower and being immediately transferred to the hospital for evaluation.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for 1 resident (Resident #85) of 19 residents reviewed, resulting in Resident #85 lacking Care Plan interventions for a neck brace, which could lead to the resident lacking necessary care and services. Findings Include: Resident #85: Care Plans A record review of the Face sheet and electronic medical record indicated Resident #85 was admitted to the facility on [DATE] with diagnoses: history of falls with facial fracture, sixth cervical vertebral fracture, fracture of first thoracic vertebra, wedge compression fracture of second thoracic vertebra, fracture nasal bones, maxillary fracture, dementia, hypothyroidism, anxiety, and hypertension. On 6/08/2026 at 10:19 AM, Resident #85 was observed sitting in a Broda chair in the dayroom on the 100 Hall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that appropriate skin care was provided for one resident (Resident #40) and that appropriate Activities of Daily Living (ADL) care for one resident (Resident #77) was provided by trained nursing staff during showers for 6 residents reviewed for skin and ADL care.

Inspectors wroteThis Citation pertains to Intake Number 3011265. Based on interview and record review, the facility failed to ensure that neurological assessments (neuro checks) were completed per Standards of Practice after unwitnessed resident falls and/or witnessed falls with a head injury for 1 resident (Resident # 80) of 3 resiudents reviewed for falls, resulting in the potential for head injury without necessary Neuro assessments. Findings Include: Accidents Resident #80: A record review of the Face sheet electronic medical record (EMR) indicated that Resident #80 was originally admitted to the facility on [DATE] and with several readmissions and diagnoses: Dementia, anxiety, depression, epilepsy, heart disease, Chronic pain syndrome, COPD, GERD, history of falls. The resident died on [DATE]. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure that staff records for Covid-19 vaccination education, and acceptance or declination of the vaccination were documented and maintained for 2 staff members Certified Nursing Assistant (CNA) L and Nurse M of 3 staff members reviewed for Covid-19 vaccinations. Findings Include: Infection Control: On 6/10/2026 at 10:09 AM, during an interview with Infection Control Practitioner O she said she said she had worked as the ICP at the facility for 2 years and was responsible for the Immunization program for residents and staff. She said staff were assessed on hire for vaccination status and she said the MCIR Michigan Care Improvement Registry was reviewed to determination staff vaccination status. The ICP O said staff were offered Covid-19 vaccinations through a pharmacy or at their providers office. [...]

Inspectors wroteThis citation pertains to intake Number 2743538. Based on interview and record review, the facility failed to ensure that licensed nursing staff possessed an active Cardiopulmonary Resuscitation (CPR) certification, resulting in the potential to not meet the needs of residents requiring CPR.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered, comprehensive care plan for 4 residents (# 8, #28, #45, #47) of 16 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and secure medication storage and ensure that supplies was labeled and not expired for two medication rooms and four medication storage carts and treatment carts reviewed for storage of drugs, biologicals and supplies.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received timely Activities of Daily Living (ADL) care and ensure that residents' preferences were followed for bathing for three residents (R24, R28, R55) of four residents reviewed for ADL care, resulting in residents receiving bed baths instead of showers, not receiving showers on scheduled days, long nails and long facial hair.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that hospice records/communication were part of the medical record for two Residents (#45 and #47) of two reviewed for hospice services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that weights were obtained, monitored as ordered, and recommended for 2 residents (#28 and #55) of three residents reviewed for nutrition. Findings Include: Resident #28: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #28 was admitted to the facility on [DATE] with diagnoses: Diabetes, depression, hypothyroidism, hypertension, asthma GERD and chronic pain. The MDS assessment dated [DATE] revealed the resident weighed 94 lbs. and was cognitively intact with a Brief Interview for Mental Status/BIMS score of 15/15. On 5/7/2025 at 1:15 PM, during an interview with Resident #28 she was observed sitting in bed eating her lunch. She appeared very thin. A record review of the electronic medical record/emr weights for Resident #28 identified the following weights: [...]

Inspectors wroteThe facility failed to inform and offer transportation to and from dialysis appointments, as part of the services at no cost, for one resident (R#55), of 2 residents reviewed for dialysis services.

Inspectors wroteBased on interview and record review the facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents (Resident #2, Resident #40) of 20 residents reviewed, resulting in incomplete baseline care plans, falls, and unmet care needs.

Inspectors wroteThis Citation pertains to Intake Number MI00142646. Based on observation, interview and record review the facility failed to ensure timely dressing changes for two residents (Reside#5, Resident #117) of four residents reviewed for wounds, resulting in missed dressing changes and the potential for worsening wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #52) and repeated falls for one resident (Resident #15) of 2 residents reviewed for falls, resulting in Resident #52 falling and sustaining a fracture and Resident #15 falling multiple times and injuring his face. Findings Include: Resident #15: A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #15, indicated the resident was admitted to the facility on [DATE] with diagnoses: Left leg above the knee amputation, diabetes, chronic kidney disease, atrial fibrillation, COPD, morbid obesity, depression, anxiety, dementia, chronic pain, weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that weight loss was monitored, addressed with updated nutritional interventions, and notify the registered dietician of the weight loss for one resident (Resident #52) of two residents reviewed for weight loss of a total sample of 20 residents, resulting in the potential for continued rapid weight loss and compromised health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the drug regimen review recommendations were reviewed by the physician in a timely manner for one resident (Resident #15) of five residents reviewed for medications, resulting in the resident receiving a medication with potential adverse effects, including falling. Findings Include: Resident #15: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #15, indicated the resident was admitted to the facility on [DATE] with diagnoses: Left leg above the knee amputation, diabetes, chronic kidney disease, atrial fibrillation, COPD, morbid obesity, depression, anxiety, dementia, chronic pain, weakness. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00140473. Based on observation, interview, and record review the facility failed to complete accurate reconciliation, documentation and wasting of narcotics which were administered to three residents (Resident #802, Resident #804, and Resident #805), resulting in narcotic administration not being consistently documented on the Medication Administration Record (MAR) when administered, narcotic sheets not being reconciled with the MAR for accuracy and improper wasting of Resident #805's narcotic medication. Findings Include: Resident #802: On 11/8/2023 at 2:15 PM, Resident #802 was observed resting peacefully in his room and there were no outward signs of pain at this time. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00140473 Based on observation, interview, and record review the facility failed to prevent misappropriation of property for one resident (Resident #801) of 5 residents reviewed for narcotic diversion, resulting in, Nurse A admitting to an unintentional overdose on Resident #801's liquid morphine during Nurse A's weekend shift at the facility.