Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Oaks At Woodfield during CMS and state inspections, most recent first.
Surveyors found that an LPN had been hired and worked without an active CPR certification, despite the job description requiring current CPR and the facility’s stated practice of obtaining CPR cards upon hire. The ED acknowledged a break in the hiring and tracking process and the absence of a specific CPR policy beyond following general regulations. Employee Services staff reported that verifying CPR certification is part of the hiring process but stated that this requirement was missed and that the LPN had not disclosed lacking an active CPR card, resulting in a failure to ensure licensed staff were properly certified to provide CPR when needed.
The facility did not ensure care plans accurately reflected residents' specific code status preferences or the use and management of specialized equipment. Several residents had advance directives or equipment in use that were not clearly documented or specified in their care plans, and staff interviews revealed confusion about care plan responsibilities and documentation.
Surveyors found expired and unlabeled glucose control solutions, undated wound care supplies, and medications without resident identification in medication rooms and carts. Keys to treatment carts containing prescription medications were left accessible, and nurse aides were allowed unsupervised access to the medication room, where the refrigerator with insulin and vaccines was unlocked. Staff interviews confirmed that these practices did not follow facility policy or professional standards.
Several residents did not receive timely or preferred ADL care, including missed scheduled showers, bed baths given instead of showers, and lack of grooming such as nail trimming and shaving. Residents with chronic conditions and cognitive intactness expressed their preferences for showers and grooming, but records and observations showed these preferences were not followed, resulting in greasy hair, long toenails, and unshaven facial hair.
The facility did not ensure that hospice records and communication were consistently included in the medical records for two residents receiving hospice services. For both residents, hospice visit notes and documentation of care provided were either missing from the medical record or only made available in hard copy after the fact, rather than being integrated into the ongoing record. One resident also reported concerns to hospice about the care received, particularly related to ileostomy and wound care.
The facility did not consistently obtain and monitor weights as ordered for two residents with complex medical needs, resulting in missed and inconsistent weight recordings despite physician orders and care plan requirements. Significant weight fluctuations were not properly addressed, and recommended monitoring was not implemented after notable changes.
A resident requiring regular dialysis was not informed or offered the facility's free transportation service, which was included in the bundled payment. Instead, the resident's family was left to arrange and provide transportation to and from dialysis appointments, without being given the option to use the facility's service. Staff interviews confirmed that transportation should have been provided and that the lack of communication led to the deficiency.
The facility did not complete required hydrostatic testing for kitchen fire suppression system cylinders, which were marked as unsatisfactory during the last two semi-annual inspections. The cylinders, installed in 2012, had not been tested at the required 12-year interval, as confirmed by the maintenance director.
A portable space heater was found on the desk in the DON's office, and staff could not verify that its heating element did not exceed the regulatory limit of 212°F. This was confirmed by the maintenance director during the survey, resulting in a deficiency for noncompliance with NFPA 101 requirements regarding portable space heaters in health care occupancies.
The facility failed to complete baseline care plans within 48 hours for two residents, resulting in falls and unmet care needs. One resident experienced multiple falls due to a delayed care plan, while another had a skin impairment that was not addressed promptly.
The facility failed to ensure timely dressing changes for two residents, resulting in missed dressing changes and the potential for worsening wounds. One resident had a wound dressing that was not changed for 10 days, while another had an unlabeled and undated drain dressing. The facility's policy lacked specific guidelines for post-surgical drains.
The facility failed to ensure appropriate interventions and supervision to prevent falls for two residents, resulting in significant injuries. One resident experienced multiple falls due to missed pharmacy recommendations to change medication, while another resident fell and fractured his hip after being left unsupervised.
A resident with Parkinson's Disease experienced significant weight loss due to insufficient food and lack of feeding assistance. The facility failed to update the care plan or notify the registered dietician, resulting in potential health risks.
The facility failed to ensure timely review of drug regimen recommendations for a resident, resulting in the resident receiving a potentially inappropriate medication and experiencing multiple falls. The pharmacist's recommendations to change the medication were not promptly addressed, leading to continued use of the medication and subsequent falls.
Failure to Ensure LPN Maintained Required CPR Certification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that licensed nursing staff possessed active Cardiopulmonary Resuscitation (CPR) certification, as required by facility job descriptions and regulatory expectations. During the survey, the surveyor requested a list of staff terminated in the last 90 days and then requested the CPR card for an LPN identified as having been employed. The Executive Director stated they could not provide a copy of this LPN’s CPR card and acknowledged that, although the facility requests CPR cards upon hire, there had been a break in the hiring process and the tracking system was not adequate. The Executive Director also stated there was no specific CPR policy beyond following regulations that require an adequate number of trained staff to be present. Record review of the LPN job description showed that a current, valid LPN license and current, valid CPR certification were required qualifications. In an interview, the Employee Services staff member reported being unaware at the time of hire that the LPN did not possess an active CPR certification and stated that the LPN had not informed them of this. The Employee Services staff member confirmed that verifying necessary items, such as CPR certification, is part of the hiring process and that this requirement was simply missed. The survey findings concluded that the facility failed to ensure that licensed nursing staff had active CPR certification, creating the potential for residents’ CPR needs not to be met prior to the arrival of emergency medical personnel, subject to physician orders and advance directives.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered, comprehensive care plans that accurately reflected the specific needs and preferences of four residents. For three residents with documented advance directives, the care plans did not specify the residents' chosen code status, despite this information being available in the medical record and flagged on the face sheet. For example, one resident was identified as Full Code in both the physician orders and face sheet, but the care plan only generically referenced code status without specifying Full Code. Another resident's care plan mentioned advanced directives but did not state the resident's DNR preference, and a third resident's care plan referenced comfort care and hospice services but omitted the code status preference, even though the face sheet indicated DNR. Additionally, for a resident on hospice with a history of stroke and pressure ulcers, the care plan referenced the use of a low air loss mattress but did not include an order or directive for the alternating pressure mattress that was in use. There was also no documentation available to staff regarding the appropriate settings for the air mattress, and the care plan did not reflect the actual equipment or its management. Interviews with staff revealed uncertainty about who was responsible for care plan completion and a lack of clarity regarding the documentation and communication of equipment settings.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and labeling practices. In the 200 Hall medication storage room, expired Assure Prism glucose control solutions were found, with no open dates on the bottles or boxes, and no unexpired control solutions available. Additionally, medications in bubble packaging were found in a medication cart without any identifying information such as resident name or room number. The nurse present was unable to identify the owner of these medications and indicated that they would use the medication since it had already been signed out for a resident. In the 300 Hall medication room, opened betadine solution and wound dressings were found without open dates, and a white powder residue was observed on one bottle. Glucose test strips were also found opened and undated, contrary to facility policy as described by the nurse. Further observations revealed that keys to the treatment cart, which contained prescription medications and treatment supplies, were left on top of the cart and accessible to multiple staff members. The nurse explained that due to having only one set of keys, they were left with the cart for shared access. The treatment cart contained various prescription medications and wound care supplies. Additionally, a nurse aide was observed being given keys to the medication room to retrieve an ice pack, entering the room unattended. The medication refrigerator inside the room, which contained insulin pens and vaccinations, was found unlocked, and nurse aides were allowed to access the room without supervision, contrary to the statements of the nurse supervisor. Interviews with nursing staff and the Director of Nursing confirmed that medication storage and access practices did not align with facility policy or professional standards. Staff acknowledged that items such as glucose control solutions, test strips, and wound care supplies should be dated when opened, and that medication carts and rooms should remain secure. The lack of proper labeling, storage, and security for medications and biologicals was consistently observed across multiple medication rooms and carts.
Failure to Provide Timely and Preferred ADL Care
Penalty
Summary
The facility failed to provide timely and appropriate Activities of Daily Living (ADL) care, including bathing and grooming, to several residents who required assistance. One resident, recently admitted with cellulitis, diabetes, and osteomyelitis, reported not receiving showers as scheduled and instead often received bed baths, despite a clear preference for showers. Documentation showed missed scheduled shower days and a lack of adherence to the resident's care plan, which specified showers twice weekly. The resident was observed with greasy hair, and staff interviews confirmed a lack of understanding regarding the difference between bed baths and partial bed baths. Another resident with multiple chronic conditions, including diabetes and depression, was observed with very long and jagged toenails, despite physician orders for nail clipping on shower days. The resident's care plan called for showers twice weekly and regular nail trimming, but records indicated only three showers were provided over a month. The resident expressed discomfort due to the length of her toenails, which were observed by staff and visitors, and reported a fear of nail clipping due to a previous bad experience. A third resident, admitted for rehabilitation after a hospital stay, had not received a shower since admission and expressed a strong preference for showers over bed baths. The resident's care plan required showers twice weekly, but records showed only one shower and multiple bed baths during the stay. The resident also had unshaven facial hair, which he did not prefer, and reported that no one had offered to shave him. Staff and documentation confirmed the lack of adherence to the resident's bathing and grooming preferences.
Failure to Maintain Hospice Documentation in Medical Records
Penalty
Summary
The facility failed to ensure that hospice records and communication were consistently included in the medical records for two residents receiving hospice services. For one resident with a history of stroke, cognitive communication deficit, hemiplegia, and a pressure ulcer, there was no documentation in the medical record of hospice communication, progress notes, or records of hospice visits and care provided. The hospice folder for this resident contained only general information and a care plan, but lacked visit documentation. The Assistant Director of Nursing confirmed that only social work staff could access hospice information through a portal, and other staff did not have access. For another resident with multiple diagnoses including spina bifida, heart failure, diabetes, and a stage 4 pressure ulcer, hospice services were reported by the resident and staff, but hospice notes and visit documentation were not found in the electronic medical record or in the hospice chart at the nurses' station. When a binder with hospice documents was eventually provided, it contained notes that were all printed on the same day, rather than being integrated into the ongoing medical record. The resident had also expressed concerns to hospice about the care received, specifically regarding ileostomy and wound care.
Failure to Consistently Obtain and Monitor Resident Weights as Ordered
Penalty
Summary
The facility failed to consistently obtain and monitor weights as ordered for two residents reviewed for nutrition. One resident, with multiple diagnoses including diabetes and chronic pain, had weights recorded inconsistently and not according to the physician's order for monthly weights by the 5th of each month. Significant weight fluctuations were noted, including a loss of 6.2 lbs over 11 days and a total loss of 10 lbs over approximately six weeks. The electronic medical record flagged an out-of-range weight, and the registered dietitian recommended weekly weights after a significant loss, but these were not obtained as recommended. The resident expressed distress about the reported low weight, stating she had never weighed below 100 lbs. Another resident, with diagnoses including congestive heart failure, chronic kidney disease, and dementia, had a physician's order for daily weights due to their medical condition and dialysis requirements. However, there were missing weight entries on three separate days, and the nurse's notes did not reflect any weights recorded on those dates. The care plan for this resident included goals to prevent unwarranted weight gain and maintain appropriate weight for dialysis, with the approach to obtain weights as ordered, which was not consistently followed.
Failure to Inform and Provide Dialysis Transportation Services
Penalty
Summary
The facility failed to inform and offer transportation services to and from dialysis appointments at no cost for a resident requiring dialysis, as part of the bundled services. The resident, who was cognitively intact and admitted with multiple diagnoses including acute renal failure, chronic kidney disease, and dementia, was scheduled for dialysis three times a week. The care plan indicated that the family was responsible for transportation, but there was no documentation that the facility had discussed or offered its own transportation services, which were included in the bundled payment and available at no extra charge. The resident's family expressed concern and confusion about why they were required to provide transportation, stating that no one from the facility had discussed this option with them upon admission. Interviews with facility staff, including the LPN, Social Services Director, and Administrator, confirmed that transportation for dialysis was a service provided by the facility and should have been offered to the resident and family. The Administrator acknowledged that there was a lack of communication regarding this service and that the family was not given the choice to use the facility's transportation. Facility policy also stated that the campus is responsible for arranging or providing transportation to and from the dialysis provider, but this procedure was not followed in this case.
Overdue Hydrostatic Testing of Kitchen Fire Suppression Cylinders
Penalty
Summary
The facility failed to ensure that its cooking facilities were protected in accordance with NFPA 96 standards. Record review on May 7, 2025, revealed that the wet chemical fire suppression system in the kitchen was past due for hydrostatic testing of the agent cylinders. Documentation from the facility's vendor indicated that the cylinders were marked as unsatisfactory during the last two semi-annual inspections. The cylinders, which were installed in 2012, require hydrostatic testing every 12 years, but this had not been completed. These findings were confirmed during an interview with the maintenance director at the time of the record review.
Plan Of Correction
K324 - Cooking Facilities Element 1: The Campus obtained a 12-year hydrostatic testing and recharge of agent cylinders on the wet chemical fire suppression system, on 5/22/2025. Element 2: A one-time audit was completed to ensure records of the system inspection were obtained and compliant. Element 3: Education was provided to the Director of Plant Operations on May 29, 2025, by the Executive Director to ensure timely and compliant inspections of the wet chemical fire suppression systems. Element 4: DPO/Designee will audit monthly x4 to ensure record of completion is present and compliant on the semi-annual inspection documents. Element 5: ED or designee will be responsible for substantial compliance. The Facility will be in substantial compliance by June 10, 2025.
Noncompliant Use of Portable Space Heater in Staff Office
Penalty
Summary
A portable space heater was observed on the desk in the Director of Nursing's office during a facility inspection. The space heater's heating element could not be verified as not exceeding 212 degrees Fahrenheit, which is a requirement for use in nonsleeping staff and employee areas according to NFPA 101 19.7.8.1. This observation was confirmed through an interview with the maintenance director at the time of the survey. The presence of the space heater in a health care occupancy area constitutes a failure to comply with regulations prohibiting such devices unless specific safety criteria are met.
Plan Of Correction
K781- Portable Space Heaters Element 1: The Campus removed the portable space heating device from the Director of Nursing office immediately upon identification. Element 2: A one-time audit was completed to ensure there were no other portable space heating devices in office spaces. Element 3: Remedial education was immediately provided to the Interim Director of Health Services regarding portable space heaters, on May 7, 2025. Element 4: DPO/Designee will audit weekly x 3 and monthly x 4 to ensure there are no portable space heating devices in health care occupancies. Element 5: ED or designee will be responsible for substantial compliance. The Facility will be in substantial compliance by June 10, 2025.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents, resulting in incomplete baseline care plans, falls, and unmet care needs. Resident #2, who was admitted with a right lower leg fracture, Alzheimer’s disease, dementia, and metabolic encephalopathy, experienced multiple unwitnessed falls since admission. Despite being assessed as high risk for falls, a care plan and interventions were not put in place until over a month later. The Minimum Data Set (MDS) nurse confirmed that the care plan for falls should have been included in the baseline care plan but was missed. Resident #40, admitted with Alzheimer’s dementia, rheumatoid arthritis, hypertension, weakness, anemia, and dizziness, had redness on the right great toe upon readmission. However, there was no care plan addressing this issue until over 72 hours later. The nurse who completed the admission assessment noted the redness but did not include any orders for treatment or monitoring in the care plan. This delay in care planning resulted in the resident's skin impairment not being addressed in a timely manner.
Failure to Ensure Timely Dressing Changes
Penalty
Summary
The facility failed to ensure timely dressing changes for two residents, resulting in missed dressing changes and the potential for worsening wounds. Resident #5, who was admitted with multiple diagnoses including a right humerus fracture, heart failure, dementia, dysphagia, and hypertension, had a wound dressing on the left shin that was not changed for 10 days. The dressing, dated 4/7, was found leaking blood on 4/17, and upon removal, green-colored drainage was present. The Director of Nursing (DON) acknowledged the error, stating the dressing was supposed to be dated 4/17, but the large amount of drainage indicated otherwise. Photographic evidence provided by the complainant supported these findings, showing the dated dressing and the exposed wound with purulent drainage. Resident #117, admitted for a short-term stay and on antibiotic therapy after abdominal surgery, had a drain dressing on the right side of the abdomen that was not labeled or dated. The resident did not know when the dressing was last changed, and the drainage bag attached to the tube contained yellowish-to-brownish fluid. The Infection Control Nurse confirmed the lack of labeling and dating and noted that the respiratory treatment apparatus was not stored in a sanitary manner. A review of the resident's electronic medical record revealed no specific treatment order for the abdominal wound drain, and the facility's policy did not include guidelines for assessing or changing wound drain dressings. The facility's policy for wound dressing changes, dated 5/10/2016, was reviewed and found to lack specific guidance for post-surgical drains or abdominal wound drains. The policy only provided guidelines for skin tears and lacerations, requiring weekly follow-up assessments to ensure healing. The absence of a comprehensive wound care policy and the failure to adhere to existing dressing change orders led to the deficiencies observed in the care of Residents #5 and #117.
Failure to Prevent Falls Resulting in Injuries
Penalty
Summary
The facility failed to ensure appropriate interventions and supervision to prevent falls for two residents, resulting in significant injuries. Resident #15, who had multiple diagnoses including an above-the-knee amputation and dementia, experienced several falls between January and March 2024. Despite pharmacy recommendations to change the resident's medication due to its potential to cause falls, the facility did not act on these recommendations in a timely manner. The resident continued to fall, sustaining injuries including an abrasion and bleeding from the nostrils after a fall on March 28, 2024. The Director of Nursing acknowledged that the pharmacy recommendations were missed and not followed up on until mid-April 2024, after the resident had already experienced multiple falls and injuries. Resident #52, who had Parkinson's Disease and was at high risk for falls, fell on March 16, 2024, while left unsupervised in a day room. The resident sustained a displaced intertrochanteric fracture of the left hip, requiring surgical intervention. The resident's care plan included placing him in a common area for easier observation, but no staff were present to supervise him at the time of the fall. The nurse assigned to the resident admitted to leaving him unattended while she passed medications, and the call light was not accessible to the resident. The Director of Nursing confirmed that the fall was unwitnessed and that the facility did not report the incident to the state. Both residents had care plans that were either not followed or inadequately updated to reflect their high fall risk. Resident #15's care plan included interventions for psychotropic drug use but did not address the pharmacy's recommendations to change the medication. Resident #52's care plan was not updated promptly after previous falls, and the intervention to place him in a common area without direct supervision proved ineffective. The facility's failure to implement and follow appropriate interventions and supervision led to significant injuries for both residents.
Failure to Monitor and Address Resident's Weight Loss
Penalty
Summary
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, who has Parkinson's Disease and other significant health issues, reported that the food provided was insufficient and that he was losing weight. His friend, who often visited, noted that Resident #52 was not receiving adequate feeding assistance or adaptive utensils to help with his tremors during meals. Despite these observations, the facility did not update the resident's nutritional care plan or notify the registered dietician about the weight loss. A review of Resident #52's medical records showed a significant weight loss over a period of time, from 164.6 lbs on admission to 156.2 lbs. The resident's care plan, which was last reviewed on 4/2/24, did not include any updates or additional interventions to address the weight loss, despite the resident's fall, hip fracture, and decreased ability to perform activities of daily living. The facility's weight monitoring policy requires a review of 5% weight changes, but the Director of Nursing and the Registered Dietician both indicated that the resident's weight loss did not trigger a red flag for significant weight loss. During an interview, the resident's family expressed concerns about the lack of communication and care planning to address the resident's nutritional needs. The family was not aware of any care conferences to discuss the resident's eating habits and food preferences. The facility's failure to monitor and address the resident's weight loss, update the care plan, and notify the registered dietician resulted in the potential for continued rapid weight loss and compromised health condition for Resident #52.
Failure to Address Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen review recommendations were reviewed by the physician in a timely manner for one resident, resulting in the resident receiving a medication with potential adverse effects, including falling. Resident #15, who had multiple diagnoses including depression, anxiety, and dementia, experienced several falls at the facility. The pharmacist made recommendations on two occasions to change the resident's medication for depression, as it was potentially inappropriate for the elderly and could lead to falls. These recommendations were not promptly addressed by the physician, leading to continued use of the medication and subsequent falls by the resident. The first recommendation was made on 1/25/2024, but it was not properly followed up on, and the resident continued to fall on multiple occasions. The second recommendation was made on 3/31/2024, and it was not until 4/16/2024 that the recommendation was signed, and a new medication order was initiated on 4/18/2024. The Director of Nursing confirmed that the initial recommendation was missed and not followed up on, and the facility was working to ensure that pharmacy recommendations were not missed again.
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Illustrative
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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.
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Nursing homes near Grand Blanc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellbridge Of Grand Blanc | 2.6 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Grand Blanc | 2.9 mi | ★★★★★ | 22 | 0 |
| Regency At Grand Blanc | 5.6 mi | ★★★★★ | 3 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 6.6 mi | ★★★★★ | 23 | 0 |
| Wellbridge Of Fenton | 7.5 mi | ★★★★★ | 9 | 0 |
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