Oakwood Snf Llc
OAKWOOD SNF LLC in MIDDLE RIVER, MD — inspection on October 9, 2025.
Found 12 citations. 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
his or her rights.
determined the facility failed to provide an environment that promotes resident respect and dignity.
The findings include:On 10/08/2025 at 11:06 AM, during an interview with Geriatric Nursing Assistant (GNA) #12, when asked why so many residents were seen wearing hospital gowns, Staff #12 replied, they don't have clothes.On 10/08/2025 at 11:13 AM, during an observation of Resident #117, he/she ambulated down 100 hallway in a hospital gown.
The gown was hanging off Resident #117's right shoulder, halfway down the arm, and exposing his/her back. On 10/08/2025 at 11:26 AM, during an interview with Registered Nurse (RN) Staff #14, stated that the Geriatric Nursing Assistant (GNA) needed to check the laundry for Resident #117's clothes.
With the surveyor present, Staff #14 opened Resident #117's closet, which revealed only one sweatshirt. At that time, Staff #14 confirmed that Resident #117 had ambulated down the hallway with areas of his/her body exposed.On 10/09/2025 at 2:10 PM, during an interview with the Assistant Director of Nursing (ADON) Staff #21 stated that a resident that would have ambulated down the hallway in only a hospital gown, which exposed their shoulder and back, would be considered a dignity issue. At this time concern was shared with ADON.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
through support of resident choice.
resident's preference to receive a shower instead of a bed bath.
This was evident for 1 (Resident
during an interview with Resident #116 stated, he/she has not had a shower in over 2 years, his/her preference is a shower, but has only received bed baths. Resident #116 continued to state, the shower room on the unit he/she resides on has not been in use and is used to store wheelchairs. On 10/06/2025 at 12:30 PM, during a review of Resident #116's medical record revealed the following: A Physician order dated 2/20/2023 weekly shower schedule on Wednesday and Saturdays on 7-3 shift.A Care plan with an initiated date of 07/29/2025 for maintenance that stated, Resident #116 is a long-term care or respite resident and requires assistance with their ADL's related to inability to perform ADLs independently, Parkinson's Disease.
With an intervention that was initiated on the date of 07/29/2025, that indicated, Dependent for bathing.
However, the care plan did not include the residents' preference to receive showers.Further review of Resident #116's medical record revealed a Documentation Survey Report v2 for September 2025 that indicated an Interventions/Task for ADL-Bathing/Showering.
The report defined bathing types as: 1 for shower, 2 for tub bath, and 3 for bed/towel bath. Resident #117 had no documentation of receiving a shower (Type 1) Resident #116 was consistently documented as receiving only bed/towel baths (Type 3) throughout the month.On 10/07/2025 at 1:05 PM, during an interview the Director of Nursing (DON) stated if a resident's preference is a shower over a bed bath, the resident should receive a shower.
The DON continued to state that the residents' care plan should reflect this preference, ensuring they receive a shower.On 10/09/2025 at 2:45 PM, the Assistant Director of Nursing (ADON) was made aware of the concern.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
The surveyor shared the concern that the facility is not a clean and home-like environment was shared with the facility administration at the exit conference.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
establish a grievance policy and make prompt efforts to resolve grievances.
it was determined the facility failed to maintain an effective Grievance system.
This was evident for 5
the complaint survey.
The findings include:On 10/06/2025 a review of intakes # 314675 and #314688 was completed, alleged by complainant's from Resident #101 and Resident #102.
The Complainant for Resident # 101 alleged had 160.00 worth of clothes missing.
The Complainant for Resident #102 alleged that she called the facility to voice concerns and never received a call return. On 10/07/2025 at 2:57 PM, in review of Facility Grievance forms from the last 6 months (April through September of 2025), provided to the Surveyor by the Administrator revealed the following:Grievance forms were unavailable for four out of six months in 2025: April, June, July, and August.
Continued review of the Grievance forms revealed, for the month of May of 2025 revealed 4 grievance forms with dates of 5/4/2025, 5/5/2025, 5/15/2025, and 5/29/2025 with documentation of the concern.
However, these forms lacked information, including: the actions taken to investigate each grievance, a summary of the conclusion reached, the date of resolution, the corrective actions implemented, and how the disposition of each grievance was communicated to the Complainant. On 10/08/2025 at 9:23 AM, during an interview the Director of Nursing (DON) stated that the facility's grievance process addresses concerns as they arise.
Staff or department heads document the concern on a Concern form, a copy of which is given to the Social Worker.
The Social Worker then distributes the form to the appropriate department.
Once a resolution is reached, it is communicated to the person who initially voiced the concern and documented on the same form. On 10/09/2025 at 9:20 AM, during an interview with the Administrator stated, Grievances are expected to be resolved within 7 days, with all details, including the investigation, resolution, and communication to the residents or family, documented on the grievance form. At this time, she verified that grievance concern forms for May 2025 were not fully documented.
The Administrator stated that the facility only had forms for May and September and was unable to locate forms for the other four requested months. At this time the Administrator was informed of the concern.
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Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
if there was anything else that I needed.
This surveyor showed him the communication flow sheets
concern as well.
When the communication flow sheet for 11/24/25 came back it was blank. He said,
A review of all the information the facility had for this incident revealed that there were no statements from the van driver, escort, resident, facility nurse, and/or the geriatric nursing assistants that were assigned to the resident in the 24-hour period prior to the resident complaining of leg pain.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
The surveyor subsequently requested a list of Hoyer lift-dependent residents, selected and examined 4 residents' charts (#108, #123, #124 and #125) including their respective care plans.On 10/9/2025 at approximately 1:00 pm, a review of Resident #108's medical records indicated a history of left-sided paralysis and left-sided weakness.
The resident's care plan also revealed dependence for activity of daily living (ADL) including mobility or transfer needs; however, there was no documented evidence to support the facility's development of a resident-specific care plan addressing Resident #108's mobility care needs and the interventions implemented to assist with mobility.On 10/9/2025, at approximately 2:00 pm, during an interview with the Assistant Director of Nursing (ADON), the surveyor inquired about the process for developing a resident care plan.
The ADON explained that care plan development is completed by an interdisciplinary team, with each department responsible for developing the care plan to reflect the treatment provided.
The ADON was presented with a scenario involving a resident with mobility concerns and she was asked to explain how the care plan would address the care needs.
She explained that the care plan should address the resident's mobility needs by specifying the mode of transfer (e.g., wheelchair or Hoyer lift dependent) and the required number of staff for transfers.The surveyor then requested that the ADON reviewed Resident #108's care plan to assess the adequacy of the facility's care plan development in addressing the resident's mobility.
Following a thorough review of the resident's care plan, the ADON acknowledged that it did not adequately address the resident's mobility needs.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
Review of their [DATE] Kardex showed that Resident #121 was showered
asked how often the residents are given showers and she said about 2-3 times a week.
She was asked how many shower rooms they have in their unit, and she said two.
She was asked if the shower rooms were functional and she said no.
She explained that they have 2 shower rooms but only use one shower room with one stall because the other shower room was currently out of order for over 3 months.
On [DATE] at 11:06 AM Staff #12 a GNA was asked again about their shower rooms, and she stated that one shower room has not been in use since she started working there, which was about 6 months ago.
Staff #10, a maintenance director also confirmed in an interview on [DATE] that the shower room on the 500 Unit has been down for 6-9 months because it was leaking water underneath the floor to the gym. He said the shower room needed remodeling, that the only shower working has one stall and is located on the 100 Units. He confirmed that the total number of working showers for the entire facility was 4 for 130 residents.
On [DATE] at 11:20 AM, The Director of nursing was made aware of the concern, she stated she will follow up. 3) The surveyor interviewed a family member of Resident #112 on [DATE] at 1:17 PM.
Family member said that on the last night the resident was in the facility the resident had an episode of incontinence.
The Geriatric Nursing Assistant (GNA) who transferred the resident out of the bed to a wheelchair so the bed linen could be changed, moved the resident out into the hallway.
The resident was in the hallway from 4 AM to 12 Noon.
This surveyor interviewed someone who requested to remain anonymous on [DATE] at 2:15 PM.
This person said the resident would call out all night asking for help.
This person said that on the last night the GNA got the resident out of bed to change the sheets and then left [him/her] in the hallway for the next 4-5 hours.
The facility was informed of the findings at the exit conference.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
During their first three days at the facility, the resident was left in bed without being bathed.
When family members attempted to clean the resident, they were informed there were no clean towels or wash-clothes available.
They had to go to a local store to purchase these items to care for the resident themselves.Review of intake #314678 also alleged that the facility never had wipes, towels and wash clothes for the residents and were always running out hindering staff from doing their jobs.
When aides tell the facility there's no linen, they suggest cutting a towel to make a washcloth or using bed sheets and pillowcases.
Those residents are left soaked from their clothes to their beds because of this.Further review of intake #314685 alleged that the facility does not have appropriate materials for caring for the clients, they do not have soap and hygiene material for some of the clients.
There was nothing to provide oral care with and they had to use a Pillowcase because there was no washcloth available to wash the Clients.On 1/7/25 at 11:30 AM and 11:35AM, observation of the linen cart on the 300 and 100 Units revealed a cart with no wash clothes, few towels and linens.On 1/7/25 at 11:40 AM in an Interview with Staff #7 a Geriatric Nursing Assistant (GNA).
The GNA was asked if the facility had enough wash clothes and they said that the facility does not have enough linen for the residents, especially wash clothes.
Staff #7 stated that this happens frequently, that most of the time, the aides have to go down to the laundry room to search for linens.
When they get there, the laundry aides are still washing the linens, and they are forced to wait till it's done before they can get any.
She was asked the reason for the shortage, and she said the facility doesn't have enough linen to provide care to residents or maybe enough laundry staff to do a quick turnaround.
She was asked how that affects residents' care, and she said that residents don't get their baths done, care is not provided timely, and residents don't get the care they deserve.
She was asked if the management are aware of the shortage and she said that they had a meeting with the new administrator and were told the issue would be resolved.In another interview with Staff #17 a laundry aid on 10/7/25 at 11:50 AM, She was asked about wash-clothes and she said they don't have any in the building because the aides hide them in the residents' closets or throw them out.
She said they do a sweep once a week going from one resident's closet to another to recover linens from where the staff stash them.
She said she only had 15 wash clothes to put out that morning for the entire building.
That the aides throw linens away in the trash when heavily soiled.
She said the linen recycling process is a mess and the residents suffer from it, that there are no washcloths on storage currently.On 10/7/25 at 12 :45 PM in a Joint interview with Staff #15 the Environmental Services Director (EVS) and the Administrator, they were made aware of the numerous complaints regarding linen shortages from residents, staff and families and were asked how that is being resolved.
Staff #15 said it's her daily struggle and that staff stash them in the residents' closet or throw them away in the trash when soiled.
She sweeps the residents' room frequently to recover stashed linens, but the aides stash them back.
The administrator said she just put in new orders for more linens and has designated a section so each shift can have their own linen.
They were made aware that this was still a concern because the issue has not been resolved and is affecting resident care.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
prevent accidents.
facility staff failed to conduct a thorough investigation into an accident thereby denying facility staff
1 (Resident #113) out of 1 resident reviewed for accidents during the complaint survey.The findings include:A review of Resident #113's clinical record was conducted on 10/7/25 at 10:00 AM as well as the review of the allegations made in intake #314682. It was revealed that on 2/23/25 the resident was found on the floor of the resident's room.
Nursing staff observed that the resident had a hematoma (localized collection of blood the pools similar to a bruise) and a laceration over the left eyebrow as well as a large amount of bleeding.
Staff assisted the resident to bed, applied ice to the hematoma, and a pressure dressing was applied over the left eyebrow to control the bleeding. 911 was called and the resident was sent to the hospital.
Further review of the clinical record on 10/7/25 revealed the resident had a diagnosis of severe intellectual disabilities.
This surveyor requested the facility fall investigation on 10/7/25. An assessment of the incident was provided but there were no interviews of staff or of the roommate.
The staff assessment of the incident included noting the resident to be alert with periods of forgetfulness, impaired memory, and gait imbalance.
Resident stated, I got up and walked to bathroom and fell hitting my head on the floor.
Staff concluded that a predisposing situational factor was ambulating without assistance.
The facility administrative team was informed of the lack of interviews which could have provided information as to the root cause of the incident and/or other information that may be used to prevent further incidents.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
The survey team informed the facility administrative team at the exit conference.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
intolerances, and preferences, as well as appealing options.
failed to properly verify pertinent information prior to meal service.
This was evident for 1 (Resident
at 1:12 PM, during an observation and interview of meal service on 300 Hall, the surveyor requested the test tray (a sample meal requested by surveyors to evaluate the quality and temperature of the food served to residents) from the 300-meal cart.
Geriatric Nursing Assistant (GNA) Staff #18 confirmed she had served the test tray to Resident #118.
Upon entering Resident #118's room, the surveyor, with GNA Staff #18 present, observed that the meal tray lacked a meal ticket. GNA Staff #18 acknowledged the absence of a meal ticket (a slip containing information that contains the resident's name, room number, diet type, food texture, liquid consistency, and allergies) and admitted that she should not have served the meal without verifying the information. On 10/08/2025 at 1:40 PM, during an interview with Licensed Practical Nurse (LPN) Staff #19, stated if a meal ticket is not on a meal tray, the meal tray would be returned to the kitchen. On 10/08/2025 at 2:00 PM, during an interview with the Director of Nursing (DON), stated Staff are to verify meal tickets against resident name and information that includes tray contents, diet, room number, texture of food, and liquid consistency.
Meal trays without a corresponding ticket should not be served. At this time the Director of Nursing (DON) was made aware of the concern.
215181 10/09/2025
Oakwood Snf LLC 1300 Windlass Drive Middle River, MD 21220
was gone.
This surveyor interviewed Staff #24 on 10/9/25 at 12:54 PM. He was asked what happened
of the van.
This was witnessed by the escort. He said when the resident got to the facility, he/she
obtained. He asked if there was anything else that I needed.
This surveyor showed him the communication flow sheets for dialysis.
This surveyor mentioned that the Dialysis center sent a write up of events via the communication flow sheets. He said he did not see it.
This surveyor said that was the survey team's concern as well.
When the communication flow sheet for 11/24/25 came back it was blank. He said, well, they would be blank because the sheet they sent would stay here in the facility.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.