Oakview Nursing & Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure garbage was removed in a timely manner. This deficient sanitation practice has the potential to affect all 60 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the enhanced barrier precautions of wearing a gown and maintaining aseptic technique while performing indwelling catheter care for 1 (R5) of 4 residents reviewed for indwelling catheter care in a sample of 31.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Certified Nursing Assistant was certified by verifying continuous employment on the Health Care Worker Registry. This has the potential to affect all 80 residents currently residing at the facility. Findings Include: The facility undated Resident Matrix provided to this surveyor on [DATE] documents 80 residents reside at the facility. The untitled and undated staff roster given to this surveyor on [DATE] documents V11 (Certified Nursing Assistant/CNA) was hired by the facility on [DATE]. V11's Health Care Worker Registry Check, dated [DATE], documents under Work Eligibility: Eligible. The registry documents the following statement. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an environment free of accident hazards for 1 (R16) of 4 residents reviewed for accidents in the sample of 42. This failure resulted in R16 acquiring a laceration to her left lower leg resulting in 12 sutures being placed. This past noncompliance occurred between 11/27/24 and 11/28/24.

Inspectors wroteBased on interview and record review, the facility failed to provide activities to residents for 4 of 4 (R31, R43, R52, and R129) residents reviewed for activities in a sample of 42. The Findings Include: R31's admission record documents an admission date of 7/16/24, and includes the following diagnoses: muscular dystrophy, cerebral palsy, and depression. R31's quarterly Minimum Date Set (MDS), dated [DATE], documents in Section C a BIMS (Brief Interview of Mental Status) score of 15, indicating R31 is cognitively intact. On 1/16/25 at 9:30 AM, R31 complained there is not enough to do in the facility, especially on the weekends. R31 stated they sometimes get coloring sheets printed off to color on over the weekend, but not every weekend. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) coding for 3 (R7, R63, R40) of 5 residents reviewed for MDS assessments in the sample of 42.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R23) of 4 residents reviewed for PASRR Screening in the sample of 42. Findings Include: R23's admission Record documented an admission date of 12/30/2022, with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, dysphasia and an additional diagnosis of bipolar disorder added 8/28/24. R23's Annual Minimum Data Set (MDS) documented an assessment date of 11/18/2024. Under section I: Active Diagnosis: I5900 it documents a Psychiatric/Mood Disorder diagnosis of bipolar disorder. On 1/15/2025 at 1:14 PM, V5 (Business Office Manager/BOM) stated R23's electronic health record (EHR) documented a diagnosis of bipolar disorder entered on 8/28/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain range of motion for 1 of 1 (R52) residents reviewed for range of motion in a sample of 42. The Findings Include: R52's admission Record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder, anxiety disorder, other specified joint disorders, morbid obesity, and other intervertebral disc displacement, lumbar region. R52's quarterley MDS (Minimum Data Set), dated 2/23/24, documents in Section GG that her functional limitation in range of motion that she has an impairment on one side of lower extermity. R52's most recent quarterly MDS, dated [DATE], documents in Section C that R52 has a BIMS (Brief Interview of Mental Status) of 15, indicating R52 is cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 1 (R52) residents reviewed for unnecessary medications in a sample of 42. The Findings Include: R52's admission record documents an admission date of 9/12/23. This same document includes the following diagnoses: major depressive disorder and anxiety disorder. R52's Minimum Data Set (MDS), dated [DATE], documents in section C, Cognitive Patterns, that R52 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R52 is cognitively intact. R52's January 2025 Order Summary Report includes the following medication orders: Ativan 1 milligram tablet by mouth every 6 hours as needed related to anxiety disorder. Ativan has a start date of 1/7/25 and an end date of 1/21/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide meals at a palatable temperature when delivering hall trays for 3 of 3 (R59, R69, and R74) residents reviewed for food palatability in a sample of 42. The The findings Include: 1. R59's admission record documents an admission date of 6/19/24, and includes the following diagnoses: Diabetes Mellitus Type 2, anxiety disorder, pressure ulcer of left heel, muscle weakness, and unspecified open wound to foot. R59's quarterly Minimum Data Set (MDS), dated [DATE] Section C, documents a BIMS (Brief Interview of Mental Status) score of 15, indicating he is cognitively intact. On 1/15/25 at 12:06PM, R59 stated he chooses to eat in his room for all meals. R59 stated most of the time, all of his food is cold when it is delivered to him. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from falls with serious injury, transferred safely with a mechanical lift using two staff members, and fall interventions were implemented to prevent falls for 4 of 4 residents (R3, R4, R8, and R9) reviewed for falls in a sample of 42. This failure resulted in R9 falling backwards out of the transport van approximately three feet onto the ground, which resulted in a fracture of her back in two places. Findings Include: 1. R9's admission Record, with a print date of 11/20/24, documents R9 was admitted to the facility on [DATE], with diagnoses that include diabetes, fibromylagia, hypertension, and difficulty in walking. R9's MDS (Minimum Data Set), dated 10/11/24, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R9 is cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 78 residents currently residing at the facility. Findings Include: The facility Resident Matrix dated 11/14/24 documents 78 residents currently reside at the facility. 1. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's Disease, atrial fibrillation, urinary incontinence, weakness, and dementia. R1's MDS (Minimum Data Set), dated 11/8/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the shower rooms on 200 and 500 hall had hot water. This has the potential to affect all residents residing on halls 200 and 500. Findings Include: On 11/19/24 at 11:00 AM, this surveyor's and the facility's digital metal stemmed thermometer used for taking temperatures for this survey was checked for accuracy using the ice-point method and was accurate within +/- 2 degrees Fahrenheit. On 11/19/24 at 11:03 AM, V1 (Regional Director of Operations) checked the water temperatures in the shower room at the shower head using a cup to hold the water on the 500 hall, and the reading was 79.7 degrees Fahrenheit. On 11/19/24 at 11:22 AM, V1 checked the water temperature in the shower room at the shower head using a cup on 200 hall, and the reading was 84.5 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of funds for 25 of 26 (R2, R5, R11, R21-R42 ) residents reviewed for misappropriation of funds in the sample of 42. Findings Include: A facility Initial Report documents: Date of incident 11/4/24. Under Status: At approximately 7:25 a (7:25 AM) it was reported by surveyor (name of surveyor) that she had a complaint about Administration at the facility stealing money. There were no specifics to the complaint, but the facility has opened an investigation into this matter. At this point there have been no reports of missing money. Quarterly trust statements were sent out on October 1, 2024, with no concerns reported. Investigation started, Medical Director, Local Police and Ombudsman have been notified. Final report will be sent within 5 days . [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure incontinence care was provided timely and shampoo/body wash was readily available for 6 of 6 (R1, R3, R8, R10, R11, and R16) residents reviewed for Activities of Daily Living in the sample of 42. Findings Include: 1. R3's admission Record, with a print date of 11/20/24, documents R3 was admitted to the facility on [DATE], with diagnoses that include diabetes, morbid obesity, neuromuscular dysfunction of the bladder, anxiety disorder, chronic pain syndrome, and pressure ulcer of right buttock. R3's MDS (Minimum Data Set), dated 10/18/24, documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 of 3 (R12) residents reviewed for abuse in the sample of 42. Findings Include: A facility Initial Report on R12 documents, On 10/28/24 at approximately 0830 am (8:30 AM), CNA (Certified Nursing Assistant) reported that she witnessed an unwanted contact between resident and staff member to his right shoulder. The resident was immediately assessed for injuries and none noted. The staff member was immediately removed from the floor and schedule until further notice. The PCP/POA/Police Department (primary care physician/power of attorney) and other reporting authorities notified Under investigation the report documents, The investigation in to this matter was conducted, and this is the result and final report. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of misappropriation of resident funds was reported to the Administrator for 1 of 26 (R4) residents reviewed for misappropriation of funds in the sample of 42. Findings Include: R4's admission Record documents R4 was admitted to the facility on [DATE], with diagnoses that include diabetes, pressure ulcer, anxiety disorder, and difficulty walking. R4's Minimum Data Set, dated [DATE] documents R4 has a Brief Interview for Mental Status score of 15, which indicates R4 is cognitively intact. An undated facility Initial Report documents, Date of incident: unknown: I received a report from a state surveyor that one of our residents (R4) is reporting having money missing from his wallet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to prevent pressure ulcers and hand hygiene was performed per current standards of practice when administering treatments for 3 of 3 (R1, R4, and R7) residents reviewed for pressure ulcers in the sample of 42. Findings Include: 1. R1's admission Record, with a print date of 11/20/24, documents R1 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's Disease, atrial fibrillation, urinary incontinence, weakness, and dementia. R1's MDS (Minimum Data Set), dated 11/8/24, documents a BIMS (Brief Interview for Mental Status) score of 04, which indicates a severe cognitive deficit. [...]

Inspectors wroteBased on interview and record review, the facility failed to care plan residents renal diets and fluid restriction for 2 of 18 residents (R11,R27) whose care plans were reviewed in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide therapeutic diets for two residents on dialysis (R11, R27) of four residents reviewed for therapeutic diets in the sample of 37.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency for two (R1 and R3) of seven residents reviewed for mechanically altered diets in the sample of seven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplements as ordered for 3 of 7 residents (R1, R2, R7) for therapeutic diets in the sample of 7.