Oakwood Care Center
Oakwood Care Center in Clear Lake, IA — inspection on November 19, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
of service 10/13/25 at 7:20 AM, documented, principal problem of septic shock. Resident #4 was admitted to Critical Care Unit (CCU) on 10/7/25 for Septic Shock.
Per nursing staff the patient was found with vomit in her mouth and was not at her baseline.
They also report that she was hypotensive (condition where the blood pressure is significantly lower than normal).
Transition to comfort care.
Sepsis secondary to pneumonia.Interview on 10/8/25 at 2:00 PM, Staff A, License Practical Nurse (LPN), acknowledged that the expectation of the nurses are to start a change in condition form in the computer software program for the resident that shows symptoms that are abnormal from their baseline and that form will generate for the next shift to document on that resident.Interview on 10/14/25 at 3:24 PM, Staff B, Registered Nurse (RN), verified that the clinical record lacked documentation of the change in condition form that needed to be completed on Resident #4.
The change in condition form will generate follow up documentation of the condition that is charted.
The staff are expected to follow the change of condition form.Interview on 10/14/25 at 3:50 PM, Staff C, LPN, verified that the clinical record that documentation of the resident lung sounds after the emesis and acknowledged that the expectation of the nurses is to generate a change in condition form in the computer software.The Change in Condition Form with no date, stated that a change in condition for an assessment of abdominal/gastrointestinal with nausea and/or vomiting needs to be charted on and followed up per guidelines.Emesis in elderly or medically complex residents is a common occurrence and can be triggered by a variety of factors, including medication side effects, acute illness, or even minor GI upset.
When emesis occurs, nursing staff must prioritize immediate safety concerns such as airway protection, monitoring for further vomiting, and ensuring the resident is stable. In the absence of overt signs of GI distress or abdominal pain, the initial nursing response may focus on supportive care and observation rather than a full GI assessment.Nursing staff are trained to use clinical judgment to determine when further assessment is warranted. If the emesis episode was isolated, with no associated abdominal pain, distension, or changes in bowel habits, the staff may have deemed it appropriate to monitor the resident for evolving symptoms rather than perform a comprehensive GI assessment at that moment.
This approach helps prevent unnecessary interventions and distress for the resident, especially if their overall condition appeared stable following the episode. It is not uncommon for aspiration pneumonia to develop several hours after an aspiration event. At the time of the initial emesis, the resident may not have displayed clinical signs of pneumonia, such as fever, productive cough, or respiratory distress.
The development of these symptoms may have occurred later, prompting the decision to send the resident to the hospital for further evaluation and management.
Thus, the absence of a GI assessment at the time of emesis does not necessarily represent a lapse in care but rather reflects the evolving nature of the clinical picture.
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