Oakwood Care Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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Oakwood Care Center in Clear Lake, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Clear Lake, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Oakwood Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.