Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Health Campus during CMS and state inspections, most recent first.
A resident with PVD returned to the facility after a left leg angioplasty and stent placement with orders to resume aspirin and Plavix, monitor the puncture site, and watch for infection or bleeding. Staff removed the pressure dressing early at the resident’s request, did not document the ordered assessments, did not create a post-op care plan, and the resident was not given Plavix as ordered. The resident later developed confusion, slurred speech, and a cool, swollen, discolored leg, and hospital records showed the stent was occluded.
A facility failed to develop and implement comprehensive person-centered care plans for several residents reviewed for unnecessary meds and dialysis-related needs. Care plans for residents with diagnoses such as osteoarthritis, Parkinson’s disease, diabetes, ESRD on dialysis, and dementia used generic diagnosis placeholders instead of resident-specific conditions, and some lacked behavior-related and self-harm care plans despite documented agitation, cursing, self-hitting, and suicidal threats. One resident’s psychotropic care plan also did not state the reason for the antianxiety medication.
Improper Food Handling During Meal Service: Food was observed being served in a manner that did not follow professional standards. A kitchen staff member placed butter packets on top of residents' food and served the plates, and another staff member was observed handling clean plates by the rims, then using the same gloves to handle meal tickets, serving utensils, cornbread, and a butter packet before placing them on a resident's plate. The DON stated staff should treat glove use like bare hands on the serving line and use tongs for bread and other food items.
A resident with Alzheimer's disease, dementia, anxiety, and depression was found to have unnecessary psychotropic medication use. The resident had severe cognitive impairment and was switched from Rexulti to Risperdal, but the meds overlapped and the resident received escalating Risperdal doses while behaviors such as agitation, pacing, cursing, self-harm, and suicidal statements were documented. Notes showed limited non-pharm interventions, and staff did not document consistent attempts before the antipsychotic change.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy. The resident's oxygen settings were not maintained as per physician's orders, with observations showing incorrect LPM settings and a dusty concentrator filter. Staff interviews revealed a lack of adherence to maintenance protocols and awareness of the required oxygen settings, compounded by the absence of a specific policy for following physician's orders.
A facility failed to maintain infection control standards during medication administration and incontinence care. A nurse administered dropped pills to a resident without replacing them, and a CNA did not perform proper hand hygiene between glove changes. These actions were against the facility's guidelines, as confirmed by the Infection Preventionist and a nurse.
The facility did not update the Posted Nurse Staffing sheets daily, as required, for one of the six days reviewed. The sheets were observed to be outdated, with the Director of Nursing indicating that the task was usually performed by the scheduler, who was absent. The facility's policy mandates daily updates to comply with federal regulations.
Failure to Follow Post-Op Stent Orders and Monitor Resident Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for a resident with peripheral vascular disease who underwent a planned angioplasty and stent placement in the left leg. The resident returned to the facility with post-procedure discharge instructions that included observing the procedure site for signs of infection, resuming aspirin 81 mg daily and Plavix 75 mg daily, and contacting the physician for worsening pain, shortness of breath, weakness, dizziness, fever, redness, swelling, warmth, or bleeding at the puncture site. The clinical record did not contain a care plan for the resident’s post-op stent placement. After the resident returned from the procedure, staff removed the pressure dressing from the left groin earlier than ordered, at the resident’s request, and the record lacked documentation of a physician order to remove it early or education to the resident about the risks and benefits of early removal. The record also lacked documentation of the ordered monitoring for temperature and left lower leg findings such as pain, redness, swelling, warmth, drainage, bleeding, and foul odor. Nursing notes documented a bruise to the left upper thigh and groin, and later the resident reported left foot pain and poor sleep, but the record did not show the ordered assessments and monitoring tied to the post-op instructions. On the morning of 5/26/25, staff noted the resident was more confused than usual, and a CNA reported the resident was unsure of her surroundings and had trouble comprehending conversation. Later that day, the resident developed slurred speech and twitching, and her left lower leg was purple, cool to touch, and swollen, prompting transfer to the ER. Hospital records showed the left distal SFA popliteal stent was occluded, and a hospital progress note later stated the resident was not receiving Plavix 75 mg daily at the facility as ordered by the vascular surgeon. Interviews also showed staff were unsure about post-op stent care, the facility had no policy for monitoring post-op patients, and the pharmacy had not received an order for Plavix from the facility.
Incomplete person-centered care plans lacked resident-specific diagnoses and interventions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for residents reviewed for unnecessary medications and dialysis-related needs. The deficiency involved 4 of 5 residents reviewed for unnecessary medications and 1 of 1 resident reviewed for dialysis. Care plans for these residents lacked resident-specific diagnoses and interventions, including care plans that used generic placeholders such as "___DX___" instead of identifying the actual diagnosis related to the resident’s condition or risk. Resident 54 had diagnoses including osteoarthritis, anxiety, and depression, and the most recent MDS indicated the resident was cognitively intact and needed partial to moderate assistance with transfers and toileting. The current ADL care plan stated the resident had potential for decline in functional status related to a diagnosis, but did not identify the specific diagnosis. Resident 86 had diagnoses including Parkinson’s disease, anxiety, and depression, and the MDS indicated no cognitive impairment with partial to moderate assistance for toileting, showering, bed mobility, and transfers, and use of an opioid. The pain care plan and ADL care plan both used generic diagnosis placeholders and did not specify the diagnosis related to pain or functional decline. Resident 1 had diagnoses including diabetes mellitus, anxiety, and depression, and the quarterly MDS indicated moderate cognitive impairment. The pain care plan and ADL care plan, both dated 10/17/23, also lacked specific diagnoses. Resident 55 had end-stage renal disease and was dependent on renal dialysis; the quarterly MDS indicated the resident was cognitively intact, but the ADL care plan dated 3/23/24 did not specify the diagnosis related to potential functional decline. Resident 33 had Alzheimer’s disease, dementia with behavioral disturbance, anxiety, and depression, and the MDS showed severe cognitive impairment. The psychotropic care plan stated the resident was receiving antianxiety medication but did not identify the reason for the medication, and the record lacked care plans related to behaviors and self-harm or suicidal threats despite progress notes documenting repeated agitation, cursing, self-hitting, threats of suicide, and other disruptive behaviors in July and August 2025.
Improper Food Handling During Meal Service
Penalty
Summary
Food was not served in accordance with professional standards in the kitchen and dining room. During a dining room observation, three residents were seen seated at a table with plastic butter packets sitting on top of their food, and a kitchen staff member brought out another plate with a butter packet on top of the food and served it to a resident. In the kitchen, Kitchen Staff 23 was observed plating food by grabbing clean plates with both thumbs over the lip of the plates, then after washing her hands and putting on gloves, she handled meal tickets, grabbed a plate with her thumb over the lip of the plate, and handled serving utensils. She then picked up a piece of cornbread and a butter packet with the same gloves and placed them on top of the food on the plate. The Dietary Manager stated that staff should treat glove use like bare hands on the serving line and that bread and other food should be picked up with tongs and placed on the resident's plate, not gloves. A current infection control policy related to food handling was requested but not provided during the survey.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medications. The resident had diagnoses including Alzheimer's disease, dementia, anxiety, and depression, and the most recent MDS indicated severe cognitive impairment and use of an antipsychotic medication. Physician orders showed Rexulti 2 mg daily, then a taper to Rexulti 1 mg daily, while Risperdal 0.5 mg at bedtime was started before Rexulti was fully discontinued, followed by increases to Risperdal 1 mg and then 1.5 mg at bedtime. The resident's care plan for psychotropic drug use included an intervention to attempt the lowest dose possible. Behavioral notes documented repeated anxiety, agitation, pacing, verbal aggression, cursing, punching walls and doors, smacking herself, and statements about killing herself. Several notes described staff reminding the resident that her spouse would visit later, offering activities, or leaving her in her room to calm down, but other non-pharmacological interventions were not documented. The psych NP changed the antipsychotic regimen after continued fixations and self-harm behaviors, and a facility pharmacy representative stated Rexulti should have been immediately discontinued when Risperdal was started because there was no good conversion dose and concurrent use increased seizure risk.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as observed during a survey. The resident, who had diagnoses including dementia, hypertension, and heart failure, was observed on multiple occasions with oxygen settings that did not match the physician's orders of 2 Liters Per Minute (LPM). On one occasion, the resident's portable oxygen tank was set at 0.5 LPM, and on another, the oxygen concentrator was set at 1.5 LPM. Additionally, the oxygen tubing was not dated, and the filter of the oxygen concentrator was dusty, indicating a lack of adherence to maintenance protocols. The resident's clinical records showed that the oxygen tubing was to be changed monthly, and the concentrator filter was to be cleaned every two weeks, as per physician's orders. However, the facility's staff did not consistently follow these orders, as evidenced by the dusty filter and incorrect oxygen settings. Interviews with nursing staff revealed a lack of awareness and adherence to the required oxygen settings and maintenance procedures. Furthermore, the facility did not have a specific policy for following physician's orders, which contributed to the oversight in providing the necessary respiratory care for the resident.
Infection Control Deficiencies in Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, leading to potential transmission of infections. During a medication pass, a Registered Nurse (RN) was observed dropping pills onto a medication cart and then administering them to a resident without replacing them. The medications involved included Keppra, Namenda, and docusate sodium. The Infection Preventionist later confirmed that any pills dropped should be disposed of and replaced before administration. Additionally, a Certified Nurse Aide (CNA) was observed providing incontinence care without proper hand hygiene. The CNA changed gloves without washing hands between glove changes and performed inadequate handwashing with only a 5-second lather. The facility's policies require a 20-second lather for effective hand hygiene. These actions were confirmed as non-compliant with the facility's guidelines by both the Infection Preventionist and a Registered Nurse.
Failure to Update Nurse Staffing Information Daily
Penalty
Summary
The facility failed to ensure that the Posted Nurse Staffing sheets contained the correct information daily for one of the six days reviewed during the survey. On June 24, 2024, at 10:39 A.M., the Posted Nurse Staffing was observed to be dated June 14, 2024, indicating that the information was not updated daily as required. During an interview on June 28, 2024, at 11:58 A.M., the Director of Nursing (DON) stated that the scheduler was responsible for posting the nurse staffing information first thing in the morning. However, the DON had been performing this task while the scheduler was out for the last few days. The DON provided a Guidelines for Staff Posting Policy, revised on May 11, 2016, which stated the purpose was to ensure compliance with federal regulations by posting the number of nursing personnel responsible for providing direct resident care on a daily basis for each shift.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tell City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Lincoln Hills Care Center | 0.7 mi | ★★★★★ | 12 | 0 |
| Heartland Villa Nursing And Rehabilitation Center | 7.7 mi | ★★★★★ | 0 | 0 |
| Waters Of Rockport Skilled Nursing Facility, The | 17.4 mi | ★★★★★ | 4 | 0 |
| Scenic Hills At The Monastery | 19.7 mi | ★★★★★ | 5 | 0 |
| Breckinridge Memorial Nursing Facility | 20 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Oakwood Health Campus.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.