Oak View Health and Rehabilitation

Inspectors wroteBased on review of facility policy, observation, record review and interview, the facility failed to ensure Resident (R)5, R98 and R23, were afforded an ongoing program of activities, based on their personal preferences and interests for 3 of 3 residents reviewed for activities.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure outdated/expired medications and biologicals were removed from 1 of 4 treatment carts. The facility additionally failed to ensure 1 of 1 medication carts and 1 of 1 treatment carts on Unit 400 was locked while unattended. The facility further failed to ensure one vial of insulin was labeled with an open date and discard date in 1 of 2 medication rooms.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to provide Resident (R)119 dignity during respiratory care, for 1 of 4 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident (R)155 and R139 was allowed the right to self-determination. Specifically, the facilitation of preferences related to attending activities and Activities of Daily Living (ADL) schedule, for 1 of 5 residents reviewed for choices.

Inspectors wroteBased on review of facility policy, observation, record review and interview, the facility failed to implement the Comprehensive Plan of Care related to providing a program of activity preferences for Resident (R)5 and R98, for 2 of 3 residents reviewed for activities.

Inspectors wroteBased on review of facility policy, manufacturer's recommendation, observation, and interview, the facility failed to ensure Resident (R)126 was free from significant medication errors. Specifically, Registered Nurse (RN)4 failed to correctly prime an insulin pen prior to administering a physician ordered dose of insulin. RN4 additionally failed to properly administer the insulin via an insulin pen for 1 of 1 residents observed receiving insulin.

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to follow safe infection control practices related to transporting soiled linen on 1 of 4 nursing units. Specifically, Certified Nursing Assistant (CNA)3 failed to bag soiled linen at point of use and was observed carrying the soiled linen down the hallway utilizing only a pair of gloves during one of one observation of a CNA transporting soiled linen unbagged. Review of the facility policy titled, Laundry Policy, states under Regulatory Basis and Guidance, Soiled linen must be stored and transported in enclosed or covered nonabsorbent containers or washable laundry bags, with no sorting or rinsing outside the laundry service area. Staff must handle, store, wash, and transport linens in a way that prevents the spread of infection. [...]

Inspectors wroteBased on review of facility policy, observation and interview, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers.

Inspectors wroteBased on review of facility policy, observation, interviews, and record review, the facility failed to (1) properly store food in 1 of 1 kitchen. Additionally, the facility failed to (2) ensure proper sanitization in the three compartment sink and the dishwasher in 1 of 1 kitchen. On 02/06/25 at 2:00 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 02/06/25 at 5:44 PM, the Administrator and Director of Nursing were notified that the failure to use sanitizer in the three compartment sink and dishwasher constituted Immediate Jeopardy (IJ) at F812. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure Resident (R)424's code status was accurately reflected in the medical record. This involved one (R424) of 32 residents reviewed for advanced directives. On [DATE] at 4:05 PM, the Administrator was notified that the failure constituted Immediate Jeopardy (IJ) at F578. On [DATE] at 7:48 AM, the facility submitted an acceptable plan of removal for the IJ at F578. Implementation of the removal plan was verified on [DATE] at 11:15 AM. The IJ was verified to be removed as of [DATE]. Findings Include: Review of the facility's policy titled, Care and Treatment, Subject: [...]

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure Resident (R)103's wound was properly managed, resulting in R103 acquiring maggots inside the wound bed on the resident's right heel. On 02/07/25 at 3:18 PM, the Administrator and the Director of Nursing (DON) was notified that the failure ensure R103's wound was properly managed, constituted Immediate Jeopardy (IJ) at F686. On 02/07/25 at 3:18 PM, the survey team provided the Administrator and the DON with a copy of the Centers for Medicare and Medicaid Services (CMS) IJ Template, informing the facility IJ existed as of 10/03/24. The IJ was related to 42 CFR 483.25 Quality of Care. On 02/11/25, the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure expired medications were removed and not stored with other medications in use for residents in 5 of 6 medication carts and 2 of 4 medication rooms.

Inspectors wroteBased on interviews and record review, the facility failed to employ a certified dietary manager.

Inspectors wroteBased on review of the facility documentation and interviews, the facility failed to employ a qualified, full-time Social Worker as required by regulation.

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to assure residents who have authorized the facility to manage any personal funds, have ready and reasonable access to those funds for 4 of 5 residents (R)22, R60, R83, and R100.

Inspectors wroteBased on review of the facility policy, record reviews and interviews, the facility failed to ensure Resident(R)40 and/or their representative was invited to and allowed to participate in care plan meetings, for 1 of 2 residents reviewed. Finding Include: Review of the facility policy titled Care Planning - Resident Participation - Policy and Signature Forms dated 10/31/22 revealed, our nursing facility supports the residents right to be informed of and participate in a care planning and treatment (implementation of care). Further review revealed, the facility will inform the resident, in a language he or she can understand, of resident rights regarding planning and implementing care, including the right to be informed of his or her total health status. [...]

Inspectors wroteBased on review of the facility policy, observations, record review, and interviews, the facility failed to provide care and services, specifically heel and ankle protection devices and a wedge cushion for offloading, while in bed per Physician orders, for Resident (R)11.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure physician order was in place for the use oxygen for Resident (R)219, for 1 of 3 residents reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure appropriate Registered Nurse (RN) coverage for 8 consecutive hours, daily 7 days a week as required by regulation.

Inspectors wroteBased on review of the facility policy, observations, and interviews, the facility failed to ensure staff were using appropriate personal protective equipment (PPE) with residents on Enhanced Barrier Precautions (EBP) 1 of 1 resident, (R)76.

Inspectors wroteBased on review of the facility policy, observations, and staff interviews, the facility failed to provide and maintain a safe, sanitary environment in the Unit 4 shower room/toilet area.

Inspectors wroteBased on interview, record review, and review of the facility's arbitration agreement the facility failed to inform residents and/or resident representatives of the right for a convenient and suitable venue location agreed upon by both parties. This failure had the potential to affect all 126 residents who resided in the facility. Findings Include: Review of a blank copy of the facility's undated Agreement to Arbitrate Disputes, Optional for Residents and Facility provided by the Director of Nursing (DON), indicated .The location of the arbitration will be located in the county in which the facility is located . [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food was served in a manner to prevent the potential spread of food borne illness; failed to ensure staff wore beard covers when in the kitchen; and failed to ensure proper glove use was adhered to when food was directly handled by dietary staff. These failures had the potential to affect 118 of 126 residents who consumed food prepared by the facility's kitchen.

Inspectors wroteBased on interview, record review, and review of the facility's arbitration agreement, the facility failed to provide an acknowledgement from the resident or resident representative the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, and the resident or his or her representative acknowledges that he or she understands the agreement. This failure affected a total of 66 out of 126 residents in the facility. Findings Include: Review of a blank copy of the undated Agreement to Arbitrate Disputes, Optional for Residents and Facility provided to the survey team by the Director of Nursing (DON), indicated signature lines for the resident name, legal representative, or agent (if any), administrator or designee name, translator (if necessary). [...]