Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Manor Nursing Home during CMS and state inspections, most recent first.
A resident with dementia, bipolar disorder, vertebral fractures, and intact cognition alleged that two CNAs were rough during a bed bath, twisting her leg and jumping on her bed and legs. The resident first told a medication aide that a CNA was rough, but the aide continued passing medications and did not immediately report the allegation to the charge nurse or administrator, and multiple LVNs and the ADON confirmed they did not receive this report. Days later, the resident repeated the allegation to another medication aide, who informed the implicated CNA instead of promptly notifying the LVN or administrator; the CNA then reported to the LVN, who attempted to contact leadership. The administrator stated she did not become aware of the allegation until many days after the incident, and the facility’s investigation documented that the event occurred well before it was reported to the state. Staff interviews and the facility’s abuse protocol showed that all staff understood that rough treatment could be abuse and that such allegations must be reported immediately, yet the required immediate reporting process was not followed, resulting in delayed internal and external reporting of the alleged abuse.
A resident with severe cognitive impairment and multiple medical conditions was observed with an oxygen concentrator and humidifier running at 2 L, but there were no corresponding oxygen therapy orders in the MDS, care plan, or physician order summary until after surveyor intervention. On several observations, the nasal cannula was off, thrown over the bedside table, with the prongs touching the carpeted floor, and later the same dated cannula was placed back on the resident while oxygen remained at 2 L. An LVN could not clarify how the oxygen was initiated, suggested a missed verbal order, and acknowledged that a cannula found on the floor should be replaced, while the DON confirmed oxygen must follow physician orders and that a cannula touching the floor presents an infection control issue.
Medication services were deficient when controlled drug counts on a hall med cart were not documented between shifts, a resident’s baclofen pill was found on the floor after the med pass, and an expired lactase supplement remained in the med storage room. The resident had hemiplegia, hx of CVA, and liver transplant status, and staff described that the resident takes pills slowly while the MA briefly returned to the cart during administration.
Unsecured treatment carts and loose pills were found in medication storage areas. A wound care nurse left a treatment cart unlocked and unattended on two occasions, including while moving between a resident room and the cart for wound care supplies. In addition, Hall 200's med cart contained 23 loose pills at the bottom, and the DON stated carts should be cleaned each shift so no loose pills remain.
Infection Control Failures During Wound Care: A wound care nurse provided wound care to a resident on enhanced barrier precautions without wearing a gown, changed gloves without performing hand hygiene between glove changes, and returned a used wound cleanser bottle to the treatment cart without sanitizing it. The DON and Administrator stated staff were expected to follow PPE, hand hygiene, and equipment sanitation practices, and the nurse acknowledged she should have followed those steps.
A resident's right to an advance directive was compromised due to an incomplete Out of Hospital-Do Not Resuscitate (OOH-DNR) form, which lacked necessary dates for signatures. This oversight led to the resident being classified as a full code, contrary to his wishes. Facility staff, including an LVN, SW, and DON, acknowledged the error, which was not addressed in the facility's Advanced Directives policy.
A facility failed to complete a Significant Change MDS assessment within 14 days for a resident admitted to hospice services. The resident, with multiple serious health conditions, was referred to hospice, but the necessary MDS assessment was not conducted. Interviews revealed that the MDS Nurse acknowledged the oversight, and the DON and Corporate Nurse were unaware of the requirement, leading to the deficiency.
A facility failed to accurately submit a PASRR Level 1 screening for a resident with Major Depressive Disorder, marking the form incorrectly as negative for mental illness. The MDS nurse, responsible for PASRR forms, was new and unaware of the diagnosis's significance, leading to the oversight. Interviews with staff revealed the MDS nurse's role in ensuring form accuracy, with oversight from the DON and Regional Care Coordinator.
A facility failed to develop a comprehensive care plan for a resident with PTSD, despite her intact cognition and diagnosis. The absence of a care plan was confirmed by the ADON and DON, who acknowledged the oversight and potential negative outcomes, such as staff being unaware of the diagnosis and triggering anxiety. The resident expressed feeling safe but experienced anxiety and irritation, which she managed independently.
A facility failed to conduct quarterly smoking evaluations for a resident with nicotine dependence and other health issues, as required by their policy. The resident was observed smoking with supervision, but the DON admitted missing evaluations in previous months, which could have necessitated additional interventions. The facility's policy mandates evaluations on admission, quarterly, and with significant condition changes.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with a gastrostomy tube and another with a tracheostomy. An LVN administered medications and performed tracheostomy care without wearing an isolation gown, despite signs indicating the need for EBP. Interviews confirmed that staff were expected to wear gowns and gloves during high-contact care activities to prevent infection spread.
Failure to Immediately Report Resident’s Allegations of Rough Care and Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property were reported immediately, and no later than two hours after the allegation was made, to the administrator and appropriate state officials. One resident with metabolic encephalopathy, Alzheimer’s dementia, anxiety, multiple vertebral compression fractures, pain, and bipolar disorder, who was cognitively intact per a BIMS score of 14, alleged that two CNAs were rough during a bed bath, twisted her leg, and jumped on her bed and legs. The resident’s care plan noted impaired cognitive function/dementia and later documented verbal behavior symptoms directed toward others, including allegations that staff attacked her, followed by expressions of affection for the same staff. The facility’s investigation identified the incident date as early in the month when two CNAs provided a bed bath, and the facility documented that it did not become aware of the allegation until later in the month, at which time the allegation was reported to the state. According to staff interviews and statements, the resident first voiced concerns about rough care on a date several days after the bed bath, when a medication aide (MA A) reported that the resident said a CNA was rough with her. MA A stated she told the resident she did not think the CNA would be rough, then continued passing medications and did not immediately report the allegation to the administrator or clearly to the charge nurse, DON, ADON, or other leadership, despite acknowledging that rough treatment could constitute abuse and that such allegations were to be reported immediately. Multiple nurses (LVN F, LVN G, and the ADON) stated that MA A did not report this allegation to them on that date, and each indicated that they would have reported any such allegation to the administrator immediately. The facility’s abuse protocol required any person observing or suspecting abuse to immediately report to the charge nurse, who must then immediately examine the patient and notify the Abuse Prevention Coordinator. Several days later, the resident again reported to another medication aide (MA E) that a CNA and another aide were rough during care and that her legs hurt because the aides were jumping up and down on her legs. MA E acknowledged that she did not report this allegation directly and immediately to the LVN or administrator, but instead informed the implicated CNA, who then reported the allegation to the LVN on duty (LVN D). LVN D stated that upon being informed by the CNA, she attempted to contact the administrator and then informed the ADON. The administrator reported that she first became aware of the allegation at approximately 4:40 p.m. on that later date, and the facility’s investigation form reflected that the incident had occurred many days earlier. Staff interviews and time card reviews confirmed the dates the CNAs worked and the timing of the bath relative to the resident’s subsequent complaints. The failure of MA A and MA E to follow the facility’s abuse protocol and immediately report the resident’s allegations to the charge nurse and administrator resulted in a delay in the facility’s awareness and reporting of the alleged abuse. In their statements, the CNAs involved (CNA B and CNA C) described providing a routine bed bath to the resident, noting that she complained of being wet and cold but did not complain of pain during the bath, and they denied hurting her or jumping on her bed or legs. They also stated that they were not informed of any complaint until many days after the bath. The resident, when interviewed later, reiterated that the aides were rough, twisted her leg, and jumped on the bed, and said she did not want them providing her care, although she could not recall the exact date or which staff member she initially told. The administrator, LVN D, CNAs, and medication aides all acknowledged in interviews that rough treatment could be considered abuse and that allegations of abuse must be reported immediately. Despite this, the facility’s own records and staff accounts showed that the initial allegation made to MA A and the subsequent allegation made to MA E were not promptly reported through the required chain, resulting in the facility not becoming aware of and not reporting the allegation to the state survey agency within the required timeframe.
Failure to Obtain Oxygen Orders and Maintain Clean Nasal Cannula for Resident on Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including oxygen therapy, in accordance with physician orders, the comprehensive care plan, and professional standards of practice for a male resident with severe cognitive impairment and multiple medical diagnoses. Record review showed that the resident’s Minimum Data Set (MDS), comprehensive care plan, and physician order summary contained no indication or orders for oxygen therapy as of mid-January, despite the resident being observed with an oxygen concentrator and humidifier running at 2 L. A physician order for oxygen at 2 L via nasal cannula every shift was only entered into the record after state surveyor intervention. The facility’s own policy required that special needs, including respiratory care, be provided consistent with physician orders and the care plan, and that RNs and LPNs manage medical conditions by following physician orders and reporting changes in condition. On multiple observations, the resident was found in bed with an oxygen concentrator and humidifier on and set at 2 L, but with the nasal cannula off and thrown over the opposite side of the bedside table, with the prongs that insert into the nostrils touching the carpeted floor. On a subsequent observation, the same nasal cannula, labeled with a date several days earlier, was on the resident while the concentrator remained set at 2 L. The resident was not interviewable. In interviews, the LVN caring for the resident on the observed days could not explain how or when the oxygen was initiated, suggested a verbal order might have been missed and not entered into the electronic health record, and acknowledged that a nasal cannula found on the floor should be replaced to prevent infection. The DON stated that oxygen should be administered according to physician orders, that nurses are responsible for ensuring orders and settings are correct, and that a nasal cannula touching the floor must be changed due to infection control concerns, consistent with the facility’s infection prevention and control program and equipment protocols.
Medication control, administration, and storage deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate control and administration of medications on the 300 hall medication cart, failed to keep a resident’s medication from being left on the floor in the resident’s room, and failed to remove an expired dietary supplement from the medication storage room. The report states that these issues involved controlled medication counts between shifts, medication administration to a resident with intact cognition and multiple neurological diagnoses, and storage of an expired product in current supply. Record review of the controlled medication count sheet for the 300 hall medication cart showed missing nursing signatures for the 10:00 p.m. to 6:00 a.m. count on 12/14/25 and the 6:00 a.m. count on 12/15/25. During interview, LVN B said she did not count the cart with the 10:00 p.m. to 6:00 a.m. nurse and let the nurse leave without counting because of an emergency situation involving a resident who was dying. She also said she could not remember whether she counted on Sunday morning, though she stated she had been trained to count controlled medications to prevent missing medications and drug diversion. Resident #98 was admitted with diagnoses including hemiplegia affecting the right side, liver transplant status, and history of cerebral infarct. The resident’s BIMS score was 13, indicating intact cognition. During observation, a small white pill was found on the floor under the bedside table in the resident’s room, and the resident identified it as baclofen that had been dropped during the morning medication pass. The resident and MA D both described that the resident removes pills from the medication cup and lines them up on a napkin before taking them, and MA D acknowledged she stepped back to her medication cart while the resident was still taking the pills. The DON and Administrator stated the nurse or MA was responsible for staying with the resident until all medications were taken. During observation of the medication storage room, a box of fast acting dairy relief lactase enzyme supplement with an expiration date of 08/25 was found in current supply. The Interim DON stated only non-expired medications should be in the facility for use and that nursing staff were responsible for removing expired medications from current use. The Administrator stated the unit manager, charge nurses, and DON were responsible for ensuring expired medications were removed and properly discarded.
Unsecured Treatment Carts and Loose Pills in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles when a treatment cart was left unlocked and unattended on two separate occasions. During one observation, the wound care nurse left the treatment cart unlocked and unattended in front of the nurse's station, facing into the main pathway. During another observation, the wound care nurse left treatment cart #1 unlocked and unattended on hall 400 while she went to a resident room to begin wound care, returned to the cart to retrieve supplies, and again left the cart unsecured. The nurse stated she did not lock the cart and acknowledged she should have locked it to prevent access to items others should not have access to. The facility also failed to ensure Hall 200's medication aides' medication cart was free of loose pills. During observation, 23 loose pills were found at the bottom of the medication cart, including multiple white tablets, capsules, an orange pill, a crushed orange/tan pill, and other loose medications. The interim DON stated carts should be cleaned at the end of each shift so there are no loose pills anywhere in the cart. The facility policy stated all drugs and biologicals must be stored in locked compartments and that medications must be under direct observation or locked in the medication storage area or cart.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection control on 1 of 4 halls observed for infection control. During an observation on 12/14/2025 at 8:45 a.m., the Wound Care Nurse began and ended wound care for Resident #74, who was on enhanced barrier precautions for wound care, without wearing a gown as personal protective equipment. During the same wound care observation, the Wound Care Nurse removed the resident’s soiled dressings and then changed gloves and put on new ones without performing hand hygiene between glove changes. At 9:00 a.m., the Wound Care Nurse took the wound cleanser bottle out of Resident #74’s room after use and placed it back in the treatment cart without sanitizing it. During interview, the Wound Care Nurse stated she should have worn a gown, should have used hand hygiene between glove changes, and should have sanitized the wound cleanser bottle before returning it to the treatment cart. She stated she had been trained and in-serviced on PPE and cross contamination. The Interim DON and the Administrator both stated their expectations were for staff to wear PPE during wound care and enhanced barrier precautions, perform hand hygiene between glove changes, and sanitize the wound cleanser bottle before placing it back in the treatment cart.
Failure to Ensure Valid Advance Directive for Resident
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was upheld, specifically for a resident who did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) order. The resident, an elderly male with chronic obstructive pulmonary disease, dementia, and atrial fibrillation, had an OOH-DNR form that was incomplete due to missing dates for both the resident's and the physician's signatures. This omission rendered the OOH-DNR invalid, resulting in the resident being classified as a full code, meaning that life-saving measures would be performed against his wishes. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), a Social Worker (SW), and the Director of Nursing (DON), confirmed the oversight. Each acknowledged the missing dates on the OOH-DNR form and the implications of this error, which meant that the resident's wishes regarding resuscitation could not be honored. The facility's Advanced Directives policy did not specify the requirement for the OOH-DNR to be fully completed, contributing to the oversight.
Failure to Complete Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident within the required 14-day timeframe after the resident was admitted to hospice services. The resident, a female with multiple diagnoses including respiratory failure, chronic obstructive pulmonary disease, major depressive disorder, dementia, anxiety disorder, and hypertension, was referred to hospice on August 19, 2024. Despite the hospice admission, the facility did not conduct the necessary MDS assessment to reflect the resident's significant change in condition. Interviews and record reviews revealed that the MDS Nurse acknowledged the oversight, admitting that a significant change MDS was not completed as required. The Director of Nursing (DON) and the Corporate Nurse were unaware of the specific requirements for conducting a significant change MDS following hospice admission, mistakenly believing that the Corporate MDS Nurse was responsible for determining when an MDS was due. This lack of awareness and communication led to the failure to perform the assessment, potentially placing residents at risk of not receiving needed services.
Failure to Accurately Submit PASRR Screening
Penalty
Summary
The facility failed to accurately submit a PASRR Level 1 (PL1) screening for a resident who was admitted with a diagnosis of mental illness, specifically Major Depressive Disorder. The resident, an elderly male, was admitted with diagnoses including seizures, anxiety disorder, and major depressive disorder. Despite these diagnoses, the PL1 form completed for the resident indicated negative for mental illness, intellectual disability, and developmental disability, and there was no PASRR Level II Screening or Form 1012 found in the clinical record from the time of admission. The MDS nurse, who was responsible for completing PASRR forms, acknowledged that the PL1 form for the resident was incorrectly marked as negative. The nurse admitted to being new at the time and unaware that Major Depressive Disorder was a PASRR positive diagnosis. The oversight was attributed to the nurse's inexperience and lack of awareness, as well as the process of inputting PL1 forms as received from referring entities without verifying the resident's diagnoses. Interviews with facility staff, including the MDS nurse, Medical Records (MR) staff, Director of Nursing (DON), Administrator, and Regional Care Coordinator, revealed that the responsibility for ensuring the accuracy of PASRR forms lay with the MDS nurse, with oversight from the DON and Regional Care Coordinator. The failure to submit a correct PL1 form was recognized as a risk that could prevent residents from receiving necessary specialized services if deemed PASRR positive.
Failure to Address PTSD in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). Despite the resident's intact cognition and diagnosis of PTSD, as indicated in her medical records and MDS assessment, there was no care plan addressing her PTSD. This oversight was identified during a review of the resident's care plan, which had been in place since 2019, and was confirmed by the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) during interviews. Both acknowledged the absence of a care plan for PTSD and recognized the potential negative outcomes, such as staff being unaware of the diagnosis and inadvertently triggering anxiety and distress for the resident. The resident, a female, expressed during an interview that she felt safe at the facility but experienced anxiety and irritation at times, which she managed on her own. The ADON admitted to not realizing the resident had a PTSD diagnosis and acknowledged the need for a care plan to address it. The DON confirmed that the nursing department was responsible for writing and updating care plans and that the resident's PTSD diagnosis had been missed during quarterly reviews. The facility's policy requires an individualized comprehensive care plan for each resident, based on a thorough assessment, to meet their medical, nursing, mental, and psychological needs.
Failure to Conduct Quarterly Smoking Evaluations
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accident hazards by not completing quarterly smoking evaluations for a resident with nicotine dependence, chronic obstructive pulmonary disease, diabetes, and peripheral vascular disease. The resident was admitted with a care plan that included smoking interventions, such as assisting the resident to the smoking area and keeping matches and lighters at the Nurses Station. However, the smoking evaluation form indicated that the last evaluation was conducted several months prior, and no subsequent evaluations were recorded in the clinical record. During an observation, the resident was seen smoking with supervision, but interviews with the Director of Nursing (DON) and the Administrator revealed that the required quarterly evaluations were missed in April and July. The DON acknowledged the oversight and noted that the lack of updated evaluations could mean that additional interventions might have been necessary, as the resident's smoking status could have changed. The facility's policy required smoking evaluations to be completed on admission, quarterly, and upon significant changes in condition, but this was not adhered to in this case.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents, leading to potential exposure to infections and communicable diseases. Resident #24, who was admitted with dysphagia and required gastric feedings and medications via a gastrostomy tube, was not provided with the necessary Enhanced Barrier Precautions (EBP) during medication administration. Despite the presence of a sign indicating the need for EBP, LVN B administered medications without wearing an isolation gown, which was a requirement for residents with indwelling medical devices. Similarly, Resident #27, who had a tracheostomy and required daily tracheostomy care, was also not provided with the necessary EBP. LVN B performed tracheostomy care without wearing an isolation gown, despite the presence of a sign indicating the need for EBP for residents with tracheostomies. Interviews with LVN B, the Director of Nursing (DON), and other staff confirmed that the expectation was for staff to wear gowns and gloves during high-contact care activities to prevent the spread of infections. The facility's policy on EBP, which required gown and glove use during high-contact resident care activities, was not followed in these instances.
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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 Vidor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vidor Health & Rehabilitation Center | 0.9 mi | ★★★★★ | 22 | 1 |
| Harmony Care At Beaumont | 7 mi | — | 35 | 2 |
| College Street Health Care Center | 8.4 mi | ★★★★★ | 0 | 0 |
| Beaumont Nursing And Rehabilitation | 8.5 mi | ★★★★★ | 16 | 1 |
| Avir At Beaumont | 8.7 mi | ★★★★★ | 4 | 0 |
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